Caregiver Forms & Info
Below are links to several forms that IHSS in-home care providers may find helpful. You'll also find other documents, including important phone numbers and information that you received at orientation.
Care Provider Address, Live-in, Deposit & Tax Forms
Download, print and submit these forms from the California Department of Social Services:
- Live-in self-certification form
- Cancel live-in self-certification form
- Change of Address and/or Telephone
- Direct payroll deposit form in ENGLISH
- Direct payroll deposit form en ESPAÑOL
- W-4 form for federal income tax withholding (links to IRA form)
Phone Numbers, Mandated Reporter, Fraud & Services
Other important documents:
- IHSS Services Description
- Your responsibilities as a Mandated Reporter
- Tips for care providers on how to prevent fraud
- How to contact Medi-Cal to report fraud by a provider or client
- Helpful phone numbers for care providers
Health and Dental Benefits:
- To be eligible for benefits, you must work 75 hours for three consecutive months and submit time-sheets by the 15th of each month for the prior month's work.
- If you meet this requirement and do not receive a packet in the mail, it is your responsibility to call Dublin Insurance Services to ask for an application packet. The phone number is listed above
- There is currently a wait list for benefits
- You must maintain the work requirements while on the wait list. Late time-sheets will disqualify your eligibility.
Service Employees International Union 2015 (SEIU):
- IHSS providers are represented by SEIU 2015
- Union dues are deducted from the 1st paycheck of the month.
- If you work less than 15 hours a month, Union dues are not deducted.
- Please call your Union Representative with any questions you may have at (855) 810-2015