Provider Enrollment - Forms Can Be Mailed To: 500 Ellinwood Way - Suite 110 - Pleasant Hill, CA 94523
Recipient Designation of Provider form
Federal Income Tax withholding
State income tax withholding (only required if withholding differs from your federal withholding amount)
Provider Workweek & Travel Time Agreement (Required when provider works for more than one recipient and/or is claiming travel time.)
Recipient and Provider Workweek Agreement (Required when a recipient has more than one provider.)
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.
Elective State Disability Insurance form. (Applies to Parent Providers, Spouse Providers and Children under 18 providing services to a parent)
Recipient request for assignment of authorized hours to providers.
Change of address form