• I DECLARE that the person named above is my choice to provide IHSS for me as authorized by the county.
• I UNDERSTAND that the above-named person cannot be paid federal and/or state IHSS funds for any services
provided to me until he/she has completed the entire provider enrollment process, which includes completing, signing
and returning (in person) the Provider Enrollment Form (SOC 426), submitting fingerprints and being cleared of
disqualifying crimes through a criminal background check, completing a provider orientation, and signing and returning
the Provider Enrollment Agreement (SOC 846).
• I UNDERSTAND that I will be informed by the county if the person I have chosen to be my provider does not complete
the provider enrollment process or if he/she is determined ineligible to be a provider.
• I UNDERSTAND that if the above-named person has been convicted of a felony which requires me to submit a provider
waiver for that individual to work for me as an IHSS provider, that individual cannot sign the waiver document as my
• I UNDERSTAND that if I choose to receive services from this person before he/she is enrolled as a provider, and
he/she is ultimately found ineligible, or after I have been informed that he/she is ineligible, I will be responsible
for paying him/her with my own money.
• I UNDERSTAND AND AGREE that neither the County nor the State is liable for any claims and/or losses to any person
caused by the above named person I choose to hire as my IHSS provider. I agree to hold harmless the State and County,
their officers, agents, and employees, and take responsibility for any and all claims and/or losses to any person caused
by the named person I choose to hire as my IHSS provider.
• I UNDERSTAND AND AGREE that the county can provide information about my authorized services and service hours
to the provider named above.
SOC 426A (4/12)
RECIPIENT’S OR LEGALLY AUTHORIZED REPRESENTATIVE’S SIGNATURE: