State of California – Health and Human Services Agency California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS)
PROGRAM PROVIDER ENROLLMENT AGREEMENT
SOC 846 (10/19) Page 1 of 6
1. I attended the required provider enrollment 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, http://www.dhcs.ca.gov/individuals/Pages/StopMedi-CalFraud.aspx
for reporting suspected fraud or abuse in the IHSS program.
2. I understand the following requirements for timesheets:
• The IHSS program can only pay me for the hours I worked providing authorized
services for the recipient that I report on my timesheet.
• By signing my timesheet I am saying that the information I reported on it is true
and correct.
• Whenever I submit a timesheet, whether on paper or electronically, it must be
completed and submitted within two weeks after the end of each pay period. If
the timesheet is properly completed and submitted on time, I will get paid within
10 days of the day it is received by the timesheet processing facility. If the
timesheet is not submitted within two weeks after the end of the pay period, my
pay will be delayed.
• I cannot sign my timesheet for the recipient or approve my timesheet
electronically (even if the recipient shares his/her Electronic Services Portal
(ESP) username and password or Telephone Timesheet System (TTS)
passcode with me) unless I am the recipient’s legal representative (court-
appointed guardian or conservator or parent of a minor recipient) and a
completed IHSS Designation of Authorized Representative form (SOC 839),
Part C has been submitted to the county.
• I cannot sign another providers timesheet for the recipient or approve another
providers timesheet electronically (even if the recipient shares his/her ESP
username and password or TTS passcode with me) unless I am the recipient’s
legal representative (court-appointed guardian or conservator or parent of
PROVIDER NUMBER
PROVIDER NAME (FIRST, MIDDLE, LAST)
State of California – Health and Human Services Agency California Department of Social Services
SOC 846 (10/19) Page 2 of 6
a minor recipient) OR I have been designated as the recipient’s timesheet
signatory through the submission of a completed SOC 839, Part C to the
county.
• Approving a timesheet, either on paper or electronically, on behalf of the
considered fraud, which can result in criminal charges being brought against
been properly completed and submitted to the county prior to me signing or
approving any timesheet on the recipient’s behalf.
• Providing false information on my timesheet is a crime and may result in a
criminal prosecution.
• If I am convicted of fraudulently reporting information on my timesheet, in
addition to any program or criminal penalties, I may be required to pay back any
overpayment I received and to pay civil penalties of at least $500, and not more
than $1,000, for each act of fraud.
3. I understand that I am required to complete the Employment and Eligibility
that I have the legal right to work in the United States.
4. I understand that I have the option to submit an Employee’s Withholding Allowance
state income tax withholding from my wages. I understand that if I do not submit
Form W-4 and/or DE 4, federal and state income taxes will not be withheld from
my wages.
5.
Authorized Hours and Services and Maximum Weekly Hours (SOC 2271), that
names my recipient(s) and the services I am authorized to perform for each
recipient to whom I provide services.
6. I received information regarding the maximum weekly hour and travel time
requirements and understand the following:
• I will get paid overtime if I work more than 40 hours in a workweek. The
workweek begins at 12:00 am (midnight) on Sunday and ends at 11:59 pm on
the following Saturday.
PROVIDER NUMBER
State of California – Health and Human Services Agency California Department of Social Services
SOC 846 (10/19) Page 3 of 6
• If I work for only one recipient, I can only work up to my recipient’s maximum
weekly hours each workweek unless we adjust my hours to balance out any
extra hours I worked during the workweek by working fewer hours in another
week of the month to avoid exceeding my recipient’s monthly authorized hours.
If these additional hours would cause me to work more than 40 hours in the
workweek or to receive more overtime hours in the month than I would in a
normal month, the recipient must obtain approval from the county before I can
work the additional hours.
• If I submit a timesheet which goes over the maximum weekly hours and causes
me to claim more overtime than I normally would claim during a workweek
without authorization from the county, I will get a violation.
• If I work for more than one recipient, the maximum number of hours I can
work in a workweek for all of my recipients combined is 66 hours. If one of my
recipients asks me to work additional hours that would cause me to work over
my 66 maximum weekly hours, I must either decline or reduce the hours I work
for another recipient so I don’t work more than 66 hours in the workweek.
• If I work for more than one recipient on the same day, I can be paid for travel
time for the time spent traveling directly from one location where I provide
authorized services to a recipient to another location where I provide authorized
my maximum weekly hours.
• The maximum amount of time I can claim for travel during a workweek is seven
hours.
• If I submit a timesheet in which I claim more than seven hours travel time in a
workweek, I will get a violation.
• If I claim more travel time hours on my timesheet than I stated on the IHSS
Program Provider Workweek & Travel Time Agreement (SOC 2255), I may
be asked by the county to provide documentation of this additional travel. If I
cannot, the extra travel time claimed may be considered an overpayment and/or
result in a fraud referral.
• For each violation I receive, there will be a consequence:
PROVIDER NUMBER
State of California – Health and Human Services Agency California Department of Social Services
SOC 846 (10/19) Page 4 of 6
First Violation
with information on how to request a county review.
Second Violation
• I will get a notice of the second violation with information
on how to request a county review. With the second
violation notice, I will have the choice to review instructional
materials about the workweek and travel time limits and
notice, I will avoid getting a second violation. However, if
I choose not to complete the review and submit the notice
within 14 calendar days of the date of my notice, I will get a
Third Violation
• I will get a notice of the third violation with information on
how to request a county review.
• If my county review request is denied, I will get information
on how to request a state administrative review of the
violation.
• I will be suspended as a provider with the IHSS program
for 90 days.
Fourth Violation
• I will get a notice of the fourth violation with information on
how to request a county review.
• If my county review request is denied, I will get information
on how to request a state administrative review of the
violation.
• I will be determined ineligible as a provider with the IHSS
program for one year.
• If I am determined ineligible to work as an IHSS provider because I get a fourth
violation, I can reapply to be an IHSS provider when the one year ineligibility
ends. I will have to complete all of the provider enrollment requirements
again, including the criminal background check, the provider orientation, and
completing all required forms before I can be reinstated.
PROVIDER NUMBER
State of California – Health and Human Services Agency California Department of Social Services
SOC 846 (10/19) Page 5 of 6
7. I understand that I will be eligible to earn and use paid sick leave once I have
when I am sick or have a medical appointment or when a family member is sick or
has a medical appointment.
8. I understand that, if my recipient has a Medi-Cal Share of Cost, he/she will be
responsible for paying this amount to me directly as a part of my wages and it will
not be included in my paycheck.
9. I understand that I am a “mandated reporter.” This means I am required by law to
report any abuse or neglect that I observe while working. The abuse may be of:
• an elder or dependent adult which must be reported to the County Adult
Protective Services immediately or as soon as feasibly possible, as required
under Welfare and Institutions Code 15630(b)(1), or
• a child which must be reported to the County Child Protective Services within
36 hours of receiving the information, as required under Penal Code 11166(a).
The abuse might be of the recipient I serve, someone else in the recipient’s home,
or anyone else.
10. I understand that Government Code section 6253.2 requires that my name,
address, home and cell telephone numbers, and personal email address be given
to the local labor organization so they may contact me to invite me to join the
union.
11. I understand that I will not be paid to perform authorized IHSS services when my
recipient is away from his/her home (at an acute care hospital, skilled nursing
facility, intermediate care facility, community care facility, or board and care facility).
If I provide any assistance to my recipient at any of these facilities, it is outside of
my work as an IHSS provider. If I claim IHSS hours on a timesheet for that time, it
will be considered fraudulent.
12.
to the evaluation of a recipient’s IHSS case.
PROVIDER NUMBER
State of California – Health and Human Services Agency California Department of Social Services
SOC 846 (10/19) Page 6 of 6
I UNDERSTAND THE IHSS PROGRAM RULES EXPLAINED AT THE PROVIDER
ORIENTATION (WHICH INCLUDES THE INFORMATION PROVIDED IN THIS FORM)
AND INFORMATION GIVEN TO ME BY THE COUNTY IHSS OFFICE. I ACCEPT
THE RESPONSIBILITY TO FOLLOW THE INFORMATION PROVIDED BY THE
COUNTY. I UNDERSTAND THAT MY FAILURE TO FOLLOW THE REQUIREMENTS
PROVIDED TO ME MAY RESULT IN MY TERMINATION AS AN IHSS PROVIDER.
IHSS PROVIDER’S SIGNATURE DATE
PROVIDER NAME (FIRST, MIDDLE, LAST)
PROVIDER NUMBER
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome