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Recipient Designation Of Provider Form Page 2

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

PART B. RECIPIENT AGREEMENT

I UNDERSTAND AND AGREE THAT:

•

The person I have chosen to be my provider cannot be paid federal and/or state

money for providing services to me until he/she completes all of the provider

enrollment requirements. These requirements include 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 returning a signed Provider Enrollment

Agreement (SOC 846).

•

The county will send me a notice telling me if the person I have chosen as my

provider does not complete the provider enrollment requirements or if he/she is not

eligible to be an IHSS provider.

•

If I choose to have this person provide services for me before he/she is enrolled as

an IHSS provider, and the county sends me a notice telling me that he/she is not

eligible to be an IHSS provider, I will have to pay him/her with my own money for

the services that he/she provided before he/she was determined ineligible to be a

provider and for any services he/she provides after the county notifies me that

he/she is ineligible.

•

Neither the county nor the State will be held responsible for any claims and/or

losses 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 to 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.

•

The county can provide information about my authorized services and service

hours to the person I have chosen as my provider. The county will send my

provider the IHSS Provider Notice of Recipient Authorized Hours and Services

(SOC 2271).

•

My total monthly authorized hours will be divided by 4 to determine my maximum

weekly hours. The maximum weekly hours is a guideline telling me the highest

number of hours my provider(s) will be able to work for me during a workweek.

However, since most months are slightly longer than 4 weeks, I will work with my

provider(s) to spread his/her hours throughout the month in order to make sure I

have all the service hours I need for the month.

•

Sometimes I may need my provider to work more than my maximum weekly hours.

I must ask for county approval to adjust my maximum weekly hours only if the

change requires my provider to work:

1. More overtime hours in the month than he/she would normally work.

PAGE 2 OF 3

SOC 426A (1/16)

Recipient Designation Of Provider Form Page 2

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