Recipient Designation Of Provider Form
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3STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
RECIPIENT DESIGNATION OF PROVIDER
INSTRUCTIONS:
•
Use black or blue ink. Print information clearly.
•
You (or your authorized representative) must complete PART A of this form to let
the county know who you have chosen to provide your authorized services.
•
If you have multiple providers, you must fill out a separate form for each person who
will be providing authorized services for you.
•
You must sign the acknowledgement in PART C of this form.
•
Please return this completed and signed form to the county. The county will keep
the original form and give you a copy.
PART A. RECIPIENT DESIGNATION OF PROVIDER
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 Social Security #*:
□
□
□
8.
Provider’s Gender (check box):
Male
Female
□
□
Parent
Child
Spouse/Domestic Partner
9.
Provider’s Relationship to
□
Conservator
Guardian
Recipient (if any):
Other ______________________
10.
Provider’s Start Date:
*NOTE: The collection of the Social Security Number is required by the Immigration Reform and Control Act of
1986, Public Law 99-603 (8 USC 1324a), for the purposes of verifying the individual’s identity and authorization
to work in the United States.
I choose the person listed above to be my IHSS provider. This person will provide some
or all of the services authorized by the county.
PAGE 1 OF 3
SOC 426A (1/16)
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