Intake - ISR


Welcome to Island Senior Resources

Private In-home Provider Application. 

Thank you for your interest in becoming a provider on our Private In-home Provider List! In order to be placed on the list, you must be clear of any disqualifying crimes as established by the WA State DSHS. https://www.dshs.wa.gov/ffa/disqualifying-list-crimes-and-negative-actions. ISR requires background checks on all providers during the application process and each year while on the list.

If you don't already have an account, you will need to set one up in our database system. It's easy, and it will make it easy for you to update information in the future. Once you set up an account, you can complete the application for processing and if accepted, you will appear on the ISR PIP list within 2 business days. 

You will need to upload a copy of your driving license or ID and relevant certifications or licenses eg: CNA, HCA, RN, so please take pictures of them and have them ready to upload when you get to that part of the application form.

 

Providers that have lived outside of Washington State in the last 3 years, must supply a copy of a completed federal background check at their own cost. If you have lived outside of Washington State in the last 3 years, please upload a copy of your federal background check.

Incomplete forms will not be accepted.

* To apply to become a State contracted individual provider go to: https://www.consumerdirectwa.com/ or call: 866/214-9899

 

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PIP List Application Form 

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Demographic data

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Disclosure Section

ISR's mission is to provide resources that enhance the emotional, physical, social, and physical well-being of seniors, adults with disabilities, and those who care for them.

To help fulfill our mission all staff, volunteers, and private in-home providers (PIP list) applicants must complete this section.

How did you hear about Island Senior Resources

Tell us how you came to know about, and want to be connected to the mission of Island Senior Resources. 

ISR File upload

Please upload copies of the following documents. 

 

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Private in-home Providers (PIP)


 
 
 
 
 
 
 
 

Please check all services offered

 

Provider - Service Area

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PIP LIST POLICIES & PROCEDURES

 

 

Eligibility: 

  • Background must be clear of any disqualifying crimes as established by WA State DSHS. A copy of this list is available upon request. 

  • If you have lived outside WA State in the past 3 years, you MUST provide, and upload a copy of your federal background check with your application at your own cost. 

To Apply: 

  • Fill in and complete all fields in the application and check "I accept"

  • Upload a current copy of your WA State ID or Driver’s License. 

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  • ISR asks for a suggested donation of $25 for processing your application and making it available to the community. After you submit your application, you will receive a donation request. 

  • If you have no history of disqualifying crimes, you will be placed on the PIP List. The entire list is then made available to community members seeking services.  

Please Note: 

  • Inclusion on this list does not constitute an affiliation or employment with Island Senior Resources.  

  • You must receive a background check annually to remain on the list. You will be notified by mail when it is time to renew. If you fail to respond by the appropriate deadline, you will be removed.  

  • It is your responsibility to keep Senior Resources updated with your current contact information. If we cannot contact you, it will be assumed you are no longer interested in being on the list.  

  • Clients that receive a copy of the PIP List will be asked to complete and return a feedback survey. Providers who receive two or more surveys with an overall score of 2 or less will be notified and will be removed from the list. In addition, negative feedback received from Clients may result in removal from the list at our discretion.