Form Soc 426 - In-Home Supportive Services (Ihss) Program - Provider Enrollment Form Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
CONTINUE READING THE INFORMATION BELOW CAREFULLY BEFORE
YOU BEGIN TO COMPLETE THIS FORM
Individual Waiver of an Exclusion for Conviction for a Tier 2 Crime
If you are found ineligible based on a conviction for a Tier 2 exclusionary crime but an
IHSS recipient (or his/her authorized representative) wishes to hire you as his/her
provider in spite of your criminal background, you may obtain a waiver as follows:
• The IHSS recipient who wishes to hire you (or his/her authorized representative) will
be informed of your conviction and will be directed to keep the information confidential.
• The recipient who wishes to hire you as his/her provider (or his/her authorized
representative) must submit an IHSS Recipient Request for Provider Waiver (SOC 862)
to the County IHSS Office or IHSS Public Authority.
• The waiver will allow you to be enrolled to provide services only for the recipient who
requested the waiver and only in the county in which the waiver was filed.
• If you, as the provider, are also the recipients’ authorized representative, you are
NOT allowed to sign the waiver on behalf of the recipient to waive crimes for which
you have been convicted. In this case, the waiver must either be signed directly by
the recipient or, if that is not possible, another individual must be declared an
authorized representative for purposes of signing this waiver.
• For more information about requesting a waiver, the IHSS recipient who wishes to
hire you as his/her provider should contact the County IHSS Office or IHSS Public
Authority.
General Exception of an Exclusion for Conviction for a Tier 2 Crime
If you are found ineligible based on a conviction for a Tier 2 exclusionary crime and you
want to be listed on a provider registry or to provide services for a recipient who has not
requested an individual waiver.
• You may apply for a general exception of the exclusion by completing the IHSS
Applicant Provider Request for General Exception (SOC 863).
• You will be required to provide backup documentation, e.g., employment history,
personal references, etc., to support your request for a general exception.
• For more information about requesting a general exception, contact the County IHSS
Office or IHSS Public Authority.
GO ON TO THE NEXT PAGE
PAGE 2 OF 5
SOC 426 (6/16)

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