Form Center

Form Center
By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

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. Information of the Individual Submitting the List Request

    If you are submitting a request for a list of IHSS Registry Providers on behalf of an IHSS Recipient and you would like a copy of the list, please note that a 'Release of Information' form or an 'Authorized Representative' form signed by the IHSS Recipient must be on file. To request a form, please call (707) 259-8359.

  4. Please write 'none' if you do not have an email address.

  5. Leave This Blank:

  6. This field is not part of the form submission.