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1024241 SOC426 Rev06-16 EN Layout 1

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GO ON TO THE NEXT PAGE
PAGE 1 OF 5
SOC 426 (6/16)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
READ THE INFORMATION BELOW CAREFULLY BEFORE
YOU BEGIN TO COMPLETE THIS FORM
Under state law, if you have been convicted of or incarcerated following a conviction for
certain exclusionary crimes within the past 10 years, you are not eligible to be enrolled
as a provider or to receive payment from the IHSS program for providing supportive
services except as specified below. There are two categories of exclusionary crimes.
• Tier 1 crimes, as set forth in Welfare and Institutions Code (W&IC)
section12305.81, include the following:
1. Specified abuse of a child (Penal Code [PC] section 273a[a]*),
2. Abuse of an elder or dependent adult (PC section 368*), and
3. Fraud against a government health care or supportive services program.
• Tier 2 crimes, as set forth in W&IC section 12305.87, include the following:
1. A violent or serious felony, as specified in PC section 667.5(c)*, and PC
section 1192.7(c)*,
2. A felony offense for which a person is required to register as a sex offender
pursuant to PC section 290(c)*, and
3. A felony offense for fraud against a public social services program, as
defined in W&IC sections 10980(c)(2)* and (g)(2)*.
A complete listing of Tier 2 crimes is available upon request from the County IHSS
Office or IHSS Public Authority.
*See attached form SOC 426C for the text of these PC and W&IC sections.
– As part of the IHSS provider enrollment process, you must submit fingerprints and
undergo a criminal background check conducted by the California Department of Justice.
– If your responses on this form or the results of the criminal background check show
that you have been convicted of, or incarcerated following a conviction for, either a
Tier 1 or Tier 2 crime within the last 10 years, you will not be eligible to be enrolled
as an IHSS provider or to receive payment from the IHSS program for providing
supportive services.
– For Tier 2 crimes, if you have obtained a certificate of rehabilitation or an expungement
(dismissal pursuant to PC section 1203.4), the conviction will not disqualify you from
working as an IHSS provider.
– If your conviction is for a Tier 2 crime, you may qualify for an individual waiver or a
general exception under certain circumstances which are described below.
– There are no waivers or exceptions allowed for Tier 1 crimes.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GO ON TO THE NEXT PAGE
PAGE 2 OF 5
SOC 426 (6/16)
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.
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
GO ON TO THE NEXT PAGE
PAGE 3 OF 5
SOC 426 (6/16)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
INSTRUCTIONS:
• Use black or blue ink to fill out. Print information clearly.
• Fill out, sign and return this form in person
to the office or location designated by the
county. Bring original federal or state government-issued identification and your
original Social Security card when returning this form.
• Complete all items in PART A, answer the questions in PART B, and read and sign
the declaration in PART C.
• The county will: 1) Review the form to make sure it is complete; 2) Make photocopies
of your identification and Social Security card; and 3) Provide you with a copy of the
completed form for your records.
• You MUST let the county know if anything you report on this form changes within
10 calendar days of the change.
PART A: PROVIDER INFORMATION
1. Full Name (First Name, Middle Initial, Last Name):
2. Date of Birth:
If you are under 18 years of age, you must
submit a valid Work Permit with this form.
3. Gender:
□ M □ F
4. Home Address (Must be physical address, not a Post Office Box*):
City: State: Zip:
5. Mailing Address (if different from home address):
City:
:
Zip:
6. Telephone Number (with Area Code):
7. Social Security Number**:
8. E-Mail Address (if any):
9. a. Driver’s License # or Government Issued ID #:
b. Expiration Date:
c. Issuing State:
10. a. Primary Spoken Language:
b. Primary Written Language:
NOTES:
* A paycheck for a provider cannot be mailed to a P.O. Box unless the county has approved a request from the
provider.
** The collection of the Social Security Number is required pursuant to W&IC 12305.81(a), and the Immigration
Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a), for the purposes of verifying the
individual’s identity and authorization to work in the United States.
CA
CA
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 426 (6/16)
GO ON TO THE NEXT PAGE
PAGE 4 OF 5
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
ANSWER THE FOLLOWING QUESTIONS BY CHECKING THE APPROPRIATE BOX:
1. WITHIN THE PAST 10 YEARS, HAVE YOU BEEN –
a. Convicted of or incarcerated following a conviction
for a Tier 1* crime?.................................................................
□ YES □ NO
b. Convicted of or incarcerated following a conviction
for a Tier 2* crime?.................................................................
□ YES □ NO
*See Page 1 of this form for a definition of Tier 1 and Tier 2 crimes.
2. IF YOU ANSWERED “YES” TO QUESTION 1.b. ABOVE, have you obtained a
certificate of rehabilitation or expungement (dismissal pursuant to PC section
1203.4) of the Tier 2 crime?........................................................
□ YES □ NO
If YES, you must provide the county with a copy of the certificate of rehabilitation or
documentation of the expungement along with this completed form.
PART C: PROVIDER DECLARATION
I UNDERSTAND AND AGREE THAT –
• I cannot receive IHSS program funds as payment for authorized services I provide to
any eligible recipient of IHSS until I have completed the entire provider enrollment
process and I have been officially enrolled as a provider by the county.
• I have 90 calendar days from the date I first began the provider enrollment process to
complete all of the enrollment requirements. If I do not complete all of the enrollment
requirements within 90 calendar days, I shall be deemed ineligible to serve as a
provider in the IHSS program and cannot be paid by the IHSS program for providing
authorized services to an IHSS recipient.
• As a part of the provider enrollment process, I must provide fingerprints and undergo
a criminal background check. I am responsible for paying the costs of fingerprinting
and the background check.
• If it is found, either through my responses on this form, the results of the criminal
background check, or some other means, that within the past 10 years, I have been
convicted of or incarcerated following a conviction for a Tier 1 exclusionary crime, I
will not be eligible to be an IHSS provider, and the recipient who wished to hire me will
be informed that I am ineligible to be a provider because of a disqualifying criminal
conviction which will not be specified.
PROVIDER’S NAME:
PART B: PROVIDER DISCLOSURE
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PAGE 5 OF 5
SOC 426 (6/16)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
PROVIDER ENROLLMENT FORM
I UNDERSTAND AND AGREE THAT –
• If it is found, either through my responses on this form, the results of the criminal
background check, or some other means, that within the past 10 years, I have been
convicted of or incarcerated following a conviction for a Tier 2 exclusionary crime, and
I have not received a certificate of rehabilitation or had the conviction expunged –
– I will not be eligible to be an IHSS provider, unless an IHSS recipient who wishes
to hire me to provide his/her services, requests an individual waiver, or I apply for
and I am granted a general exception; and
– The IHSS recipient who wishes to hire me as his/her provider will be informed of my
conviction and the types of crimes for which I was convicted, and he/she will be
directed to keep the information confidential.
IF I AM ENROLLED BY THE COUNTY AS AN IHSS PROVIDER,
I UNDERSTAND AND AGREE THAT –
• If the person I provide services for receives IHSS through the Medi-Cal program, I will
be considered to be a Medi-Cal provider of personal care services. Therefore, I will be
required to comply with all Medi-Cal program rules relating to the provision of services.
• Payment for the authorized services I provide to an IHSS recipient will be from federal,
state and/or county IHSS funds and any false statement I provide, including false
entries on the timesheet, or withholding of information may be prosecuted under
federal and/or state laws.
• I will reimburse the IHSS program for any overpayments paid to me and any overpayment,
individually or collectively, may be deducted from a future paycheck for services I
provide to any recipient of IHSS.
• I will provide all services without discrimination based on race, religion, color, national
or ethnic origin, gender, age, sexual orientation, or physical or mental disability.
I declare, UNDER PENALTY OF PERJURY, that all of the information I have
provided on this form is true and correct to the best of my knowledge, and that I
agree to the declaration and agreements listed above.
Signature: ____________________________________________________ Date: ___________________________
Printed Name: _________________________________________________
County
Representative’s Signature (Optional): DATE:
PROVIDER’S NAME:
PART C: PROVIDER DECLARATION (Continued)
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