Form Soc 431 - Personal Care Services Program - Contract Agency Enrollment
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1STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PERSONAL CARE SERVICES PROGRAM
CONTRACT AGENCY ENROLLMENT
Instructions:
•
This form is to be completed in duplicate.
•
This form must be completed for each contract and prior to enrollment by each public or private agency
contracted to provide services under the Personal Care Services Program.
•
Part I is to be completed by the authorized representative of the contract agency.
•
Part II is to be completed by the County.
•
The original form is to be maintained by the County and a copy given to the contract agency.
PART I - CONTRACT AGENCY
CONTRACT AGENCY NAME
STATE CONTRACT NUMBER
ADDRESS (Street, City, Zip)
PHONE
(
)
CERTIFICATION STATEMENT
•
I certify that all employees of this agency are qualified to provide the care authorized.
•
I certify that all claims submitted to the County for services to recipients of the Personal Care
Services Program and provided by this agency will be provided as authorized for the recipient.
•
I understand that payment of these claims will be from federal and/or state funds and that any false
statement, claim, or concealment of information may be prosecuted under federal and/or state laws.
•
I agree that services will be offered and provided without discrimination based on race, religion,
color, national or ethnic origin, sex, age, or physical or mental disability.
SIGNATURE AND TITLE OF AUTHORIZED REPRESENTATIVE
DATE
PART II - RECORD RETENTION
The County shall ensure that the contract agency shall keep all records which are necessary to fully
disclose the extent of services to the client for a minimum of three years from the date of service during
the effective dates of this contract. At the expiration of this contract the County shall keep said records
for a minimum of three years from the date of service. On request, the County shall furnish records for
audit to the State of California or the U.S. Department of Health and Human Services or their duly
appointed representatives.
SIGNATURE AND TITLE OF AUTHORIZED COUNTY REPRESENTATIVE
DATE
COUNTY
PART III - HEALTH SERVICES APPROVAL
The Department certifies that the agency named above will be an enrolled Medi-Cal provider of
personal care services.
California Department of Health Services
SOC 431 (5/03)
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