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Request for a List of IHSS Registry Providers

  1. IHSS Recipient Information
    Please provide as much information as possible. Only the pink boxes are required.
  2. How would the recipient like to receive the list?
  3. Does the recipient need any accommodations to make the list more accessible? (Optional)
  4. Information of the Individual Submitting the List Request

    Anyone is welcome to submit a list on behalf of a Recipient. 

    To receive a copy of the list, a signed 'Release of Information' form or an 'Authorized Representative' form must be on file. For more information, please call (707) 259-8359.

  5. Please write 'none' if you do not have an email address.
  6. Leave This Blank: