This form is a sample of an agreement between an elderly or disabled client and a Caregiver who operates as an independent contractor and provides personnel to assist Client to live at home and to have as much control over the home environment and life as possible under the circumstances. Caregiver's personnel also assist Client with the activities of daily living, scheduling medication, assistance with mobility, accompanying Client on errands and appointments, and such other services as agreed between Client and Caregiver.
In this agreement, Client waives damages for simple negligence of Caregiver, but not gross negligence or misconduct that is intentional or criminal in nature. Courts generally will not enforce waivers of this type of misconduct since such a waiver would be deemed to be against public policy because it would encourage dangerous and illegal behavior.
Caregiver Form Application With Database In San Bernardino
Category:
State:
Multi-State
County:
San Bernardino
Control #:
US-00458BG
Format:
Word;
Rich Text
Instant download
Description
Free preview
Form popularity
FAQ
Complete a provider enrollment packet. Submit identification documents (unexpired government issued photo ID and social security card). Complete a Live Scan and pass a criminal background check through the California Department of Justice “DOJ” using the Riverside County Live Scan form.
Eligibility. To become an IHSS Provider, you must: Complete and sign all mandatory forms included in the IHSS Program Provider Enrollment Packet and return it to the County IHSS Office. Be fingerprinted and go through a criminal background check by the California Department of Justice (DOJ).
How to Become an IHSS Provider Go to an IHSS Provider Orientation given by the county. Complete, sign and return the IHSS Program Provider Enrollment Form (SOC 426) directly to the County IHSS Office or IHSS Public Authority. Complete and sign the IHSS Provider Enrollment Agreement (SOC 846) .
You (as the consumer/recipient), your family, friends, physicians or anyone who has knowledge about your needs can make a referral to IHSS by calling. Call: You must make a referral for IHSS to the San Bernardino County Department of Aging and Adult Services by calling the IHSS Central Intake Unit at (877) 800-4544.
Meet eligibility criteria Live at home or in a shelter, but not in a board and care facility, nursing home, or hospital. Receive Medi-Cal or qualify for Medi-Cal. Provide health care certification Form SOC 873, completed by a licensed health care professional, showing your need for services.
Attend 2-hour, group Orientation in San Francisco Valid state or U.S. government-issued photo ID. Original Social Security card. A Work Authorization (required only if your Social Security card states "Valid for work only with DHS or INS authorization") Completed the IHSS Provider Packet (including SOC 426A).
How to Become an IHSS Provider Go to an IHSS Provider Orientation given by the county. Complete, sign and return the IHSS Program Provider Enrollment Form (SOC 426) directly to the County IHSS Office or IHSS Public Authority. Complete and sign the IHSS Provider Enrollment Agreement (SOC 846) .
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.
You (as the consumer/recipient), your family, friends, physicians or anyone who has knowledge about your needs can make a referral to IHSS by calling. Call: You must make a referral for IHSS to the San Bernardino County Department of Aging and Adult Services by calling the IHSS Central Intake Unit at (877) 800-4544.
Go to an IHSS Provider Orientation given by the county. Here you will learn important information about the program and the requirements for you to follow as a provider. Complete, sign and return the IHSS Program Provider Enrollment Form (SOC 426) directly to the County IHSS Office or IHSS Public Authority.