IHSS & PA Secure Document Submission
Fields marked with an asterisk (*) are required to submit your information
FIRST NAME
LAST NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
CONTACT PHONE
EMAIL
NOTE
You may add up to
10 files at a time
.
Files cannot be over
10 megabytes each
.
Only BMP, GIF, JPEG, JPG, PDF,
or
PNG
are accepted.
Click
Browse/Choose File
to select a file to upload
File 1:
Clear File
Submit
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Terms of Use
.