After completing the IHSS Provider Designation Form, you must submit it to your county IHSS office. Check the specific submission instructions provided by your county, which may include mailing the form to a physical address, delivering it in person, or using a county-provided online submission portal. Make sure to keep a copy of the completed form for your records. It is important to notify the county within 10 calendar days if there are any changes to your provider. My advice is to follow submission instructions carefully to ensure timely processing and to avoid any delays or issues with your IHSS services.

There are no specific important dates mentioned for this form in 2024 and 2025.

The purpose of the IHSS Provider Designation Form is to officially designate an individual as the provider of In-Home Supportive Services (IHSS) for a recipient. This form must be filled out by the recipient or their legally authorized representative to notify the county of their chosen provider. The form ensures that all required information, declarations, and agreements are documented and acknowledged by both parties. Filling out this form is crucial for ensuring the continuity and quality of the services provided to the IHSS recipient. By formally designating a provider, counties can ensure the provider meets all necessary qualifications and that the IHSS recipient receives the proper care and support. Additionally, it provides a clear agreement between the recipient, provider, and county regarding responsibilities, preventing potential disputes and misunderstandings.

• 1. Recipient's Name: The full name of the person receiving IHSS services.
• 2. County IHSS Case #: The unique case number assigned to the recipient by the county.
• 3. Provider's Name: The full name of the person designated to provide IHSS services.
• 4. Provider's Address: The complete address of the provider, including city, state, and ZIP code.
• 5. Provider's Telephone Number: The contact phone number of the provider.
• 6. Provider's Date of Birth: The birth date of the provider.
• 7. Provider's Gender: The gender of the provider, with options to check Male or Female.
• 8. Provider's Relationship to Recipient: The relationship of the provider to the recipient, if any, with options such as Parent, Conservator, Child, Guardian, Spouse/Domestic Partner, or Other.
• 9. Provider's Start Date: The date on which the provider is expected to start providing services.
• 10. Recipient Declaration: A section to declare the chosen provider, including an understanding of terms, conditions, and eligibility.
• 11. Signature: Signature of the recipient or their legally authorized representative to validate the form.
• 12. Printed Name: Printed name of the person signing the form.
• 13. Date: The date on which the form is signed.

If you fail to submit this form, the county and state may not recognize your chosen provider for IHSS services. This may result in interrupted services or the provider not being compensated.

• Loss of Services: Failure to submit the form may result in a pause or termination of IHSS services.
• Unpaid Provider: The chosen provider may not receive payment for services rendered.
• Compliance Issues: Non-compliance with county and state requirements can lead to administrative issues and delays.

• 1. Designate a New Provider: When you want to choose a new provider for your IHSS services.
• 2. Change of Existing Provider: When there are changes to your current provider's information or status.
• 3. Multiple Providers: When you have multiple providers and need to submit different forms for each.
• 4. Notification of Provider Start Date: When informing the county of the provider's intended start date.
• 5. Compliance with County Requirements: When ensuring that you meet all county documentation requirements for IHSS services.