1. Recipient’s Name:
2. County IHSS Case #:
3. Provider’s Name:
4. Provider’s Address:
City, State, ZIP Code:
5. Provider’s Telephone Number:
6. Provider’s Date of Birth:
7. Provider’s Gender (check box): Male Female
8. Provider’s Relationship to Recipient (if any):
9. Provider’s Start Date:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
SOC 426A (4/12)
Parent Child Spouse/Domestic Partner
Conservator Guardian Other: _______________
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
RECIPIENT DESIGNATION OF PROVIDER
INSTRUCTIONS:
Use black or blue ink. Print information clearly.
You (or your legally authorized representative) must fill out both sides of this form to let the county know who you have
chosen to provide your services.
You (or your legally authorized representative) must sign the declaration at the bottom to show that you understand and
agree to all of the terms and conditions listed.
If you have multiple providers, you must fill out a separate form for each person who will be providing services.
Please return this form to the county. The county will keep the original form and give you a copy.
You must let the county know if you change your provider(s). You must tell the county within 10 calendar days of the
change.
RECIPIENT DECLARATION
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
authorized representative.
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:
DATE:
PRINTED NAME:
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome