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 (nnn-nn-nnnn)
*DOB (mm/dd/yyyy)
  *First Name
*Last Name
  *Email
*Confirm Email
  *Primary Language
*Gender
  *Address
Address 2
  *City
State
*Zip
   Home Phone
 Cell Phone
 Other Phone
Fax Number
   I opt in to recieve SMS messages
  Mobile Carrier:
 
  Submit Application
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