Provider Enrollment Form

THERE ARE TWO DIFFERENT APPLICATION TYPES (PROVIDER TYPES)

Individual Provider: You are an Individual Provider if you already have an eligible IHSS client to work for

Registry Provider: You are a Registry Provider if you do not have a client or if you would like to be referred to new clients

PLEASE MAKE SURE TO SELECT THE CORRECT APPLICATION TYPE FROM THE DROP DOWN
Application Type*
Provider Number
SSN *
DOB*
 
First Name*
Last Name*
 
Email Address*
Confirm Email*
 
Primary Language*
Gender*
 
Address*
Address 2
 
City*
State*
Zip*
 
 
 
 
Fax Number   
Mobile Carrier
 
Submit Application