Form SOC 426A. In-Home Supportive Services (IHSS) Program Recipient Designation Of Provider

Form SOC 426A is a crucial document within California's In-Home Supportive Services (IHSS) Program, which provides assistance to eligible aged, blind, and disabled individuals to remain safely in their own homes. This form is designed to facilitate the process of designating a provider to offer authorized services to the IHSS recipient. It gathers necessary information about the recipient and the chosen provider, outlines agreements, and ensures compliance with program rules.

Key Sections and Fields:

PART A - Recipient Designation of Provider:

• Recipient's name, IHSS case number, and provider's details such as name, address, telephone number, date of birth, Social Security number, and gender.
• Provider's relationship to the recipient (parent, child, spouse/domestic partner, conservator, guardian, other).
• Start date for the provider's service.

PART B - Recipient Agreement:

• Explanation of the process and requirements for a provider to be paid using federal and/or state funds.
• Acknowledgement of the recipient's understanding that the provider must complete enrollment requirements.
• Notification that the county will inform the recipient if the chosen provider is not eligible or fails to complete requirements.
• Acknowledgement that the county and state are not responsible for claims or losses arising from the chosen provider's actions.
• Acknowledgement that information about authorized services and service hours may be shared with the provider.

PART C - Recipient Acknowledgment:

• The recipient's and authorized representative's signatures and printed names to acknowledge understanding and agreement with the requirements outlined in the form.

Purpose: The Form SOC 426A serves to ensure that recipients of the IHSS program have the ability to designate providers of their choice to assist them with authorized services while adhering to program regulations. The form outlines the responsibilities of both recipients and providers, and it helps recipients make informed choices about their care. The form's completion and submission contribute to the effective functioning of the IHSS program by ensuring that recipients' needs are met and that services are provided by qualified and enrolled providers.