Provider Forms

Provider Forms

• Caregiver Support Group Meetings (PDF)
• Change of Address Form (PDF) - Please mail completed form to:
  Placer County Public Authority
  11512 B Avenue
  Auburn, CA 95603
• Direct Deposit Form (PDF) - Please mail completed Direct Deposit Forms to:
  Provider Forms Processing Center
  P.O. Box 1697
  West Sacramento, CA 95691-6697
• Provider Education Packet (PDF)
• In-Home Supportive Services and Registry Provider Handbook Addendum (PDF)
• Registry Provider Application (apply online)
• Sick Leave Claim Form (PDF) - Please mail completed form to:
  Sick Leave Processing Center
  P.O. Box 989700
  West Sacramento, CA 95798-9700
• Vaccine Medical Accompaniment Form
• W-4 2022

Training Videos