Provider Enrollment Form

Start the IHSS Provider Application Process

Becoming an IHSS provider and joining the Public Authority Registry are two separate processes.

Step 1: Complete Individual Provider Enrollment form

All applicants must first complete the Individual Provider enrollment process, whether they currently have an IHSS recipient to work for or plan to join the Registry.

Step 2 (Optional): Apply to Join the Provider Registry

After starting the Individual Provider enrollment process, you may separately apply to join the Public Authority Registry if you would like to be referred to IHSS recipients who are looking for providers.

Applying to the Registry does not replace the Individual Provider enrollment process and does not guarantee a referral or employment.
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