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
• 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 provider’s timesheet for the recipient or approve another
provider’s 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 NAME (FIRST, MIDDLE, LAST)