Form Hcs 9183 - Home Care Organization Association Request
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
COMMUNITY CARE LICENSING DIVISION
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
HOME CARE SERVICES BUREAU
HOME CARE ORGANIZATION ASSOCIATION REQUEST
The Home Care Organization (HCO) Association Request may only be used to request a criminal record clearance
transfer between California Department of Social Services’ licensed organizations/facilities and/or Trustline. Please fax
this completed request, along with copies of driver’s license or other valid photo I.D. for each individual listed, to (916)
322-6310 or mail to: California Department of Social Services, Home Care Services Bureau, 744 P Street, MS T8-3-90,
Sacramento, CA 95814. If driver’s license or photo I.D. is not submitted, the transfer will not be completed.
Please note: if this form is received for an individual with a criminal record exemption, the transfer will not be
completed. To request an exemption transfer, please fax a completed LIC9188, LIC508, and copy of photo I.D. to
the Caregiver Background Check Bureau at (916) 754-4589 for processing.
HOME CARE ORGANIZATION INFORMATION
HOME CARE ORGANIZATION NAME
HOME CARE ORGANIZATION NUMBER
REPRESENTATIVE NAME
AREA CODE/TELEPHONE
(
)
PLEASE ASSOCIATE THE FOLLOWING INDIVIDUALS TO THE ABOVE HCO:
NAME
PERSONNEL/
DRIVERS
DATE OF
PER TYPE: HCA
REGISTRATION
LICENSE/
BIRTH
(Home Care Aide)
ID NUMBER (PER ID)
ID NUMBER
Or Employee
I DECLARE UNDER PENALTY OF PERJURY THAT THE STATEMENTS ON THIS FORM
ARE CORRECT TO THE BEST OF MY KNOWLEDGE.
HOME CARE ORGANIZATION REPRESENTATIVE SIGNATURE
DATE
HCS 9183 (6/17)
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