STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM RECIPIENT DESIGNATION OF PROVIDER INSTRUCTIONS: Use black.
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How to fill out the Recipient Designation online
Filling out the Recipient Designation is an essential step in choosing a provider for in-home supportive services. This guide provides clear and supportive instructions to help you complete the form accurately online.
Follow the steps to fill out the Recipient Designation effectively.
- Press the ‘Get Form’ button to retrieve the Recipient Designation form and open it in the online editor.
- In PART A, fill in the recipient’s name and county IHSS case number. Clearly print this information to ensure legibility.
- Enter the provider’s name, address, city, state, ZIP code, and telephone number. This section is vital for identifying the person who will provide authorized services.
- Provide the provider’s date of birth and Social Security number. Remember, collecting this information is necessary for verifying the individual’s identity and eligibility.
- Indicate the provider's gender by checking the appropriate box for 'Male' or 'Female.'
- If applicable, specify the provider's relationship to the recipient. You can choose from options such as 'Parent,' 'Child,' 'Spouse/Domestic Partner,' 'Conservator,' or 'Guardian,' or write in 'Other.'
- Fill in the provider's start date. This marks when the provider is expected to begin offering services.
- Once all fields are complete, sign the acknowledgment in PART C. Ensure that you or your authorized representative reviews all provided information before signing.
- Finally, return the completed and signed form to your county. They will retain the original form and provide you with a copy for your records.
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