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 Provider.

  • 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.  

**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. Selecting the incorrect application type may delay the enrollment process.***

 

Once you click submit, you will receive an “Invitation to Portal” email from noreply@jumpfaster.com 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 noreply@jumpfaster.com to your contacts.

  *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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