In-Home Supportive Services (Ihss) Program. Provider Enrollment Agreement. - California Page 4
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
•
If I get terminated as a provider because I get multiple violations, when the one
year termination ends, I will have to complete all of the provider enrollment
requirements again, including the criminal background check, provider
orientation, and completing all required forms, before I can be reinstated.
4. I understand that I am required to complete the Employment and Eligibility
Verification (Form I-9), a form kept on file by the recipient, which states that I have
the legal right to work in the United States.
5. I understand I have the option to submit an Employee’s Withholding Allowance
Certification (Form W-4) to request federal income tax withholding and/or California
Employee’s Withholding Allowance Certification (Form DE 4) to request state
income tax withholding from my wages. I understand that if I do not submit Form
W-4 and/or DE 4, no federal or state taxes will be withheld from my wages.
6. I understand that authorized IHSS services cannot be performed when the recipient
is away from his/her home unless my recipient gets approval from his/her social
worker for such services.
7. I understand that in the future I will receive the In-Home Supportive Services
(IHSS) Program Provider Notification of Recipient Authorized Hours and Services
(SOC 2270) that names the recipient and the services I am authorized to perform
for that recipient.
8. I will cooperate with state or county staff to provide requested information related to
the evaluation of a recipient’s IHSS case.
I UNDERSTAND THE IHSS PROGRAM RULES EXPLAINED AT THE PROVIDER
ORIENTATION OR INFORMATION GIVEN TO ME BY THE COUNTY IHSS OFFICE. I
ACCEPT THE RESPONSIBILITY TO FOLLOW THE INFORMATION PROVIDED BY
THE COUNTY. I UNDERSTAND THAT FAILURE TO FOLLOW THE REQUIREMENTS
PROVIDED TO ME MAY RESULT IN BEING TERMINATED AS AN IHSS PROVIDER.
__________________________________________________________________
IHSS Provider’s Signature
Date
PAGE 4 OF 4
SOC 846 (9/14)
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