IHSS Care Provider Forms

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Self Service Options, Technology, Online

As an IHSS Care Provider, you can now request certain changes without having to come in to the office or call us!  

Please see below for form submission instructions


Effective February 1st, 2019

We will no longer be accepting the following forms in our Public Authority Office Lobby: 

Address Changes (SOC 840)

Wage Verification (IHSS 0177)

Recipient and Provider Request Form (IHSS 0168)

Travel Time Agreement (SOC 2255)

IHSS Existing Provider Packet

Direct Deposit  (do not submit to county office; see form for return instructions)

As not all forms are submitted to the County Office, please see below for specific submission instructions


IHSS Existing Provider Packet

If you are an active IHSS Care Provider, and will be caring for a new Recipient, you will not need to enroll as a new provider again. Simply complete the IHSS Existing Provider Packet.

IHSS Existing Provider Packet

Once completed and signed by the Recipient, the form can be submitted by

mail to:
County of Fresno Department of Social Services
P.O. Box 1912
Fresno, CA 93718-9889

or by fax to:
(559) 243-7485  

 After you have submitted your packet, please allow 2 weeks processing time to you receive your first set of timesheets. 


IHSS Recipient & Care Provider Request Form

Please complete the IHSS Recipient & Care Provider Request Form to make the following requests:

Order Replacement Timesheets

Terminate a Care Provider

Reinstate (rehire) a Care Provider


Change of Address or Telephone Number

As an IHSS Care Provider you are required to inform us of any change in your contact information by completing and signing the IHSS Change of Address and/or Telephone within ten (10) days.

Change of Address or Phone (SOC 840) English

Change of Address or Phone (SOC 840) Spanish


Employment & Wage Verification

It is important to remember that the County of Fresno and Department of Social Services In-Home Supportive Services (IHSS) ARE NOT THE EMPLOYER. However, verification that the care provider is and/or has been employed by one or more recipients of the IHSS program can be provided.

Take me to the Employment & Wage Verification page!


Workweek & Travel Time Agreement

Providers who work for multiple recipients will need to complete and sign a Workweek & Travel Time Agreement. This agreement explains the workweek and travel time limitations, and includes areas for you to plan your workweek schedule and record the estimated travel time between recipients’ locations each week. Completing the SOC 2255 will help make sure that you do not work more or travel more than you are allowed to each workweek.

IHSS Provider Workweek and Travel Time Agreement (SOC 2255)


Once completed and signed, forms can be submitted by:

USPS mail to:

Department of Social Services
IHSS - Public Authority
P.O. Box 1912
Fresno, CA 93718-1912

Fax to:

IHSS - Public Authority
(559) 600-7762

Or Email us!


Direct Deposit

As an IHSS Care Provider, you can request that your payments are automatically deposited into your checking or savings account instead of being sent to you through the mail. What are the advantages of direct deposit? Your payroll checks can't get lost in the mail or stolen from your mailbox, purse or pocket. You may have access to your money sooner because you don't have to wait for the check to arrive through the mail.

If you would like to enroll via paper form you can Download Direct Deposit Forms. Please remember that you must submit a separate form for each IHSS Recipient that you want payments to be directly deposited for. If there are no timesheets submitted for 60 days, you will be dis-enrolled from direct deposit and will have to re-enroll. Once all sections of the form are complete please sign, date and mail to:

Provider Forms Processing Center 
PO Box 1697 
West Sacramento, CA 95691-6697

NEW! Direct Deposit Online Enrollment Service is Now Available!

Beginning February 12th, 2018, IHSS Care Providers now have the option of enrolling for Direct Deposit Online! The new Online Direct Deposit Enrollment Service allows current, active IHSS/WPCS providers in all California counties the ability to electronically enroll, change or dis-enroll by using the website, instead of using a paper form.

1. You must be registered on the ESP Website
2. You must be actively working for an IHSS and/or WPCS recipient
3. Have an open checking or savings account
4. Have your Bank Name, Account Number and the Routing Number
5. IHSS Providers are eligible for direct deposit if they meet the following requirements:

I want more information on Electronic Direct Deposit Service

If you have questions about IHSS Direct Deposit, you can call the Provider Direct Deposit Help Desk during business hours at 1-866-376-7066 (select option 2 for Direct Deposit assistance).


 

 W-4/DE 4

 As an IHSS Care Provider, you have the option to complete a W-4 and DE 4 to have Federal & State taxes withheld from your wages.

 Form W-4 (2019) English

Formulario W-4 (2019) Spanish

DE 4

Once completed and signed, W-4/DE 4 forms should be submitted by mail to:

IHSS Payroll Management Unit
PO Box 1660
West Sacramento, CA 95961-6660

 Instructions for completing your W-4 & DE-4. Unfortunately, we cannot provide any tax advice, please contact the IRS or your tax preparer for questions regarding withholdings or exclusions. For more information, please visit the IRS website (www.irs.gov).

 

 

 

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