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State of California Health and Human Services Agency Department of Health Care Services Home and CommunityBased Setting Characteristics PROVIDER ATTESTATION RESIDENTIAL SETTINGS Provider Enrollment
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01
Read the provider residential attestation form carefully to understand the information required
02
Gather all the necessary documents and information needed to fill out the form
03
Start filling out the form by entering your personal details such as name, address, and contact information
04
Provide details about your residential status and whether you own or rent the property
05
If you rent the property, mention the name and contact information of the landlord or property management
06
Indicate the duration of your stay at the residential address
07
If there are any other residents living with you at the same address, provide their details as well
08
Check all the statements and declarations mentioned in the attestation form that apply to your situation
09
Sign and date the form to confirm the accuracy of the information provided
10
Submit the completed provider residential attestation form to the appropriate authority or organization

Who needs provider residential attestation?

01
Individuals or organizations who are required to verify their residential address for a particular purpose
02
Service providers or businesses that need to validate the residential address of their clients or customers
03
Organizations or institutions that require proof of residency as part of their application or enrollment process
04
Government agencies or departments that need to gather information for official records or compliance purposes
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Provider residential attestation is a form that certifies the residential status of a service provider.
All service providers are required to file provider residential attestation.
To fill out provider residential attestation, you need to provide information about your residential status and sign the form.
The purpose of provider residential attestation is to verify the residential status of service providers.
Provider residential attestation must include information about the provider's residential address and any other relevant details.
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