Provider Enrollment - Forms Can Be Mailed To:                         500 Ellinwood Way - Suite 110 - Pleasant Hill, CA  94523

SOC 426A
Recipient Designation of Provider form

Federal Income Tax withholding

State income tax withholding (only required if withholding differs from your federal withholding amount)

SOC 2255
Provider Workweek & Travel Time Agreement (Required when provider works for more than one recipient and/or is claiming travel time.)

SOC 2256
Recipient and Provider Workweek Agreement (Required when a recipient has more than one provider.)

SOC 2298
Live-in Certification form. By completing this form, the provider certifies that the wages received  for providing IHSS and/or WPCS services to the recipient (living in the same address as the provider) will be excluded from federal and state personal income taxes.

SOC 409
Elective State Disability Insurance form. (Applies to Parent Providers, Spouse Providers and Children under 18 providing services to a parent)

SOC 838
Recipient request for assignment of authorized hours to providers.

SOC 840
Change of address form