How to become a ihss provider in ga form 2026

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The document is the In-Home Supportive Services (IHSS) Program Provider Enrollment Form from the California Department of Social Services. It outlines eligibility criteria for potential providers, specifically regarding criminal convictions categorized as Tier 1 and Tier 2 crimes. Individuals with certain convictions within the past 10 years are ineligible to enroll or receive payment unless they obtain a waiver or exception under specific conditions. The form also details the enrollment process, including fingerprinting and background checks, and emphasizes the importance of providing accurate information.

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Click ‘Get Form’ to open the 'how to become a ihss provider in ga' form in our editor.
Begin with Part A: Provider Information. Fill in your full name, date of birth, gender, and home address. Ensure all information is printed clearly using black or blue ink.
Next, provide your Social Security Number and government-issued ID details. If applicable, include your mailing address and contact number.
Move on to Part B: Provider Disclosure. Answer the questions regarding any convictions for Tier 1 or Tier 2 crimes by checking the appropriate boxes.
In Part C: Provider Declaration, read through the statements carefully. Sign and date the declaration to confirm your understanding and agreement.
Finally, review all sections for completeness before submitting the form as instructed. Remember to bring original identification when returning it.

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