Provider Enrollment Form

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Welcome to the In-Home Supportive Services (IHSS) Provider Self-registration Portal for Riverside County.

By completing this form, you are about to begin the enrollment process to become an IHSS Registry Caregiver. You are a Registry Caregiver if you do not have a client or if you would like to be referred to new clients.

         ***Note: If you are a new provider and already have a client, do not use this form. Please contact HOME at 888-960-4477.

  • All the fields below are required to be completed (SSN, DOB, First & Last Name, Email, Language, Gender, Address, City, State, Zip, and at least one valid phone number (both checkbox and field must be completed).

  1. Do not leave Primary Language, Gender, or State as “undetermined”.

  2. For Provider Number, please put "Unknown" if you don't have a number or do not remember your number.

Once you click submit, you will receive an “Invitation to Portal” email from with your link to log in and continue completing the enrollment process. To ensure that emails received from us are not sent to your junk mail (SPAM) mailbox, please add to your contacts.

  *Application Type:   Provider Number:  

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