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