In-Home Supportive Services (Ihss) Program. Provider Enrollment Agreement. - California
Download a blank fillable In-Home Supportive Services (Ihss) Program. Provider Enrollment Agreement. - California in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete In-Home Supportive Services (Ihss) Program. Provider Enrollment Agreement. - California with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT AGREEMENT
IHSS PROVIDER CASE NUMBER
PROVIDER NAME (FIRST, MIDDLE, LAST)
1. I attended the required orientation for IHSS providers and I understand and agree
to the following:
•
I was given information about being a provider in the IHSS program.
•
I was informed of my responsibilities as an IHSS provider.
•
I was informed of the consequences of committing fraud in the IHSS program.
•
I was given the Medi-Cal toll-free telephone fraud hotline number, 1-800-822-6222
and web site,
for reporting suspected fraud or abuse in the IHSS program.
2. I received training on, and understand how to complete my timesheet.
•
I understand that I should report on my timesheet only the time I worked
providing authorized services for the recipient.
•
I understand that by signing my timesheet I am saying that the information I
reported on it is true and correct.
•
I understand that I must submit my timesheet (signed by both my recipient and
me) within two weeks after the end of each pay period. If I submit my timesheet
on time, I will get paid within 10 days of the day it is received at the timesheet
processing facility. If I do not submit my timesheet on time, my pay will be
delayed.
•
I understand that if I am convicted of fraudulently reporting information on my
timesheet, in addition to any criminal penalties, I may be required to pay civil
penalties of at least $500, and not more than $1,000, for each violation of fraud.
3. I received information and training regarding the workweek and travel time
requirements. This information and training included the following topics:
Overtime Pay
•
Beginning January 1, 2015, IHSS providers will get paid overtime (one and
a half times the regular pay rate) when they work more than 40 hours in a
workweek. The workweek begins at 12:00 a.m. (midnight) on Sunday and ends
at 11:59 p.m. on the following Saturday.
PAGE 1 OF 4
SOC 846 (9/14)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Soc 2271 - In-home Supportive Services (ihss) Program Provider Notification Of Recipient Authorized Hours And Services And Maximum Weekly Hours
Legal
In-home Supportive Services (ihss) Program. Live-in Family Care Provider Overtime Exemption - California
Legal
In-home Supportive Services (ihss) Program And Waiver Personal Care Services (wpcs) Program Live-in Self-certification Cancellation Form For Federal And State Tax Wage Exclusion
Legal
Form Ihss-e 004 - In-home Supportive Services (ihss) Program - Notice Of Non-receipt Of Exemption From Workweek Limits Provider Agreement (apd 006)
Legal
Form Ihss-e 007 - In-home Supportive Services (ihss) Program - Notice To Recipient Of Provider's Expiration Of Exemption From Workweek Limits
Legal
Form Ihss-e 002 - In-home Supportive Services (ihss) Program - Notice To Provider For Discontinuance Of Exemption From Workweek Limitations For Extraordinary Circumstances
Legal
Related Categories
Parent category: Legal