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Who is it For: You must also be a California resident. You must have a Medi-Cal eligibility determination. You must live at home or an abode of your own choosing (acute care hospital, long-term care facilities, and licensed community care facilities are not considered own home).
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.
This form allows the IHSS applicant/recipient or his/her legal representative to. choose an Authorized Representative for the IHSS program and identifies the functions the Authorized Representative may perform on his/her behalf. This form is only for the IHSS program.
Contact your local In-Home Supportive Services (IHSS) county office. You can find the contact information for your local IHSS office on the California Department of Social Services website (.cdss.ca.gov) or by calling 1-866-376-7066.
You can become a provider by attending an in-person provider orientation or by completing the provider orientation process online. After the orientation you will be required to visit an IHSS office to: Present your photo ID and Social Security card; Complete and return the required enrollment forms; and.

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Complete, sign and return the IHSS Program Provider Enrollment Form (SOC 426) directly to the County IHSS Office or IHSS Public Authority. For additional guidance, contact your County IHSS Office or IHSS Public Authority. Do not send the form to CDSS. Complete and sign the IHSS Provider Enrollment Agreement (SOC 846) .

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