Fillable IN-HOME SUPPORTIVE SERVICES PROGRAM RECIPIENT REQUEST FOR PROVIDER (California)

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IN-HOME SUPPORTIVE SERVICES PROGRAM RECIPIENT REQUEST FOR PROVIDER (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
RECIPIENT REQUEST FOR PROVIDER WAIVER
(ADDRESSEE)
COUNTY OF:
Notice Date:
Applicant Provider Name:
Recipient Name:
Recipient Case Number:
IHSS Office Address:
IHSS Office Telephone Number:
I, ___________________________________, am submitting this waiver request to the
________________________________________________ in order to hire the person
COUNTY/PUBLIC AUTHORITY/NON-PROFIT CONSORTIUM
named below to be my In-Home Supportive Services (IHSS) provider. I understand
he/she has been denied eligibility to be paid from the IHSS program, due to a felony
criminal conviction(s). Despite this information, I accept the responsibility for my
decision, and the possible risks involved, in allowing this person to work in my home
as an IHSS provider.
I have chosen to hire ___________________________ to be my IHSS provider and
acknowledge that he/she has been convicted of the following crime(s):
Date of Conviction Penal Code Section Felony Conviction Description
1.
2.
3.
4.
5.
SOC 862 (5/16)
PAGE 1 OF 3
___________________________________________________
________________________________________________ __________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS)
RECIPIENT REQUEST FOR PROVIDER WAIVER
AS THE IHSS RECIPIENT WHO WILL HIRE THIS PERSON TO PROVIDE IN-HOME
SUPPORTIVE SERVICES, I UNDERSTAND AND AGREE TO THE FOLLOWING
STATEMENTS AND ACTIVITIES LISTED BELOW
• I am hiring a person who has been convicted of the felony crime(s) listed on this
form.
• I am required to keep this person’s criminal conviction information confidential, and I
am prohibited, by law, from sharing any part of it with any other individual or entity.
• I am completing this waiver request form, which applies only to the crime(s) listed
on this form.
• This waiver only applies in the county to which I am sending it. If I move to a new
county, the person I am hiring as my provider will have to go through another criminal
background check and I will have to complete and submit another waiver request
form in the new county before he/she can work and be paid for providing services
to me as my provider.
• If the county notifies me that this person is convicted of an additional disqualifying
felony crime(s) in the future, I will be required to complete and submit another
waiver if I wish to continue receiving services from this person.
• A notice will be sent to me when the county has accepted this waiver.
• The county will send a timesheet to the provider I have chosen to hire only after this
waiver has been accepted.
By signing this form, I accept the responsibility for hiring the person named on this form
to work in my home. I understand the County and the State of California are immune
from any liability, due to the risk of any actions that may occur, because of my decision
to hire him/her as my IHSS provider.
This document may only be signed by the recipient or by an authorized representative
who is not the provider named on this form.
SIGNATURE OF RECIPIENT OR RECIPIENT’S AUTHORIZED REPRESENTATIVE
PRINT NAME DATE
SOC 862 (5/16)
PAGE 2 OF 3
_______________________________
_______________________________
_______________________________
_______________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
Without an approved waiver to hire the person named on this form, you will be responsible
for paying him/her with your own money for any services provided.
Submit this form within ten (10) calendar days from the “Notice Date” listed on the
upper right corner of Page 1. You may submit this form by mail or in person to your
IHSS county, Public Authority, or Non-Profit Consortium at the following address:
By mail: _______________________________
In person: _______________________________
SOC 862 (5/16)
PAGE 3 OF 3
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IN-HOME SUPPORTIVE SERVICES PROGRAM RECIPIENT REQUEST FOR PROVIDER (California)

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Completed 12 March 2021

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