Calaveras County Provider Registry Application Form printable pdf download

Calaveras County Provider Registry Application Form

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FOR OFFICE USE ONLY:

Accepted: _____ / ____ / _____

Verified by:

STATUS:

L/SCAN DATE:

COMMENTS:

PROVIDER APPLICATION FORM

SOCIAL SECURITY NO.:

FIRST NAME:

MIDDLE INITIAL:

LAST NAME:

HOME PHONE: (209)

CELL PHONE:

MESSAGE PHONE:

PAGER:

PHYSICAL ADDRESS:

State: CA Zip:

MAILING ADDRESS:

DATE of

BIRTH:

GENDER (Optional):

Male

Female

CA ID#:

Expiration Date:

PROOF of IDENTIFICATION:

CA DL#:

Expiration Date:

Passport #:

Expiration Date:

Other ID:

Expiration Date:

PROOF of AUTO INSURANCE:

(Insurance Agency/Broker Name)

Expiration Date:

DMV PRINT-OUT:

Yes

N/A (IP does not drive)

DAYS and HOURS of AVAILABILITY: (Check all that apply)

Mornings:

Select All

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Afternoons:

Select All

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Evenings:

Select All

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Overnight:

Select All

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Number of hours you would like to work:

CIRCLE ONE = per week OR per month

IP CHARACTERISICS

CONSUMER PREFERENCES

Do you smoke?

Yes

Work for a smoker?

Yes

Form of transportation?

Bus/Transit

Car

Live-in position?

Yes

Read/Write English?

Yes

Client preference:

Male

Female

Either

Will you use a car?

Yes

Drive client’s vehicle?

Yes

Infectious Diseases?

Yes

Work for clients w/ pets?

Yes

Willing to work:

Holidays

Overnight

On-Call

1 – 2 Hours

Private Pay

IHSS-PA Provider App. (v7 – 01/07)

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Calaveras County Provider Registry Application Form

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