HOME AND COMMUNITY SERVICES (HCS)

AREA AGENCY ON AGING (AAA)

DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)

HCS / AAA / DDA Individual Provider Contractor Intake Instructions

An Individual Provider (IP) is: A person working under contract with the Department of Social and Health Services (DSHS), who
acts at the direction of a DSHS client living in his or her own home and provides that client with personal care and/or DDA respite
care.
This form is intended for individuals and not business entities. If you are completing this form for a business entity, please STOP and
request a Contractor Intake from the person who sent you this form.
Complete form in its entirety and return to:
1. Home and Community Services (HCS) if you will be working for a client of HCS, or
2. Area Agency on Aging (AAA) if you will be working for a client of an AAA, or
3. Development Disabilities Administration (DDA) if you will be working for a client of DDA.
Part A – Individual Provider Information (Mandatory for all Contractors)
1. Contractor Information: The Contractor Name is your name as it appears on your Social Security card. If you have additional
addresses, you may submit them on a separate sheet of paper. For any additional addresses, please make sure you label the
type of address (example: home, mailing, etc.).
Identification: You must provide originals of the following for identification purposes.
Note: The name on picture ID and SS card must be a reasonable match (i.e. Jane Smith and Jane Lynn Smith is an acceptable
match but not Janelle Lynette Smith; or Linh T. Nguyen and Linh Trang Nguyen is a reasonable match but not L. Trang Lam).
a. Unexpired picture ID. This includes any one (1) of the following:
● Driver’s license issued by the state of Washington or another state in which the applicant resides or has recently resided
in (by law, you have 30-days to get your WA driver license once you establish residency in WA state). Note: if someone
is temporarily living in WA state, like a student, or lives in a neighboring state but works in WA, an out of state license or
state ID would be acceptable; or
● Identification card, which includes the applicant’s photo, issued by the state of Washington or another state in which the
applicant resides or has recently resided; or
● Passport; or
● Military ID or military dependent ID; or
● Permanent Resident Card; or
● Employment Authorization Card; or
● Native American tribal photo ID card; and your
b. Social Security Card. This includes any one of the following:
● SS card that shows your name and Social Security number, or
● SS card that shows your name and Social Security number and notes “VALID FOR WORK ONLY WITH DHS
AUTHORIZATION” or “VALID FOR WORK ONLY WITH INS AUTHORIZATION” (DSHS is not able to accept SS cards
which note “not valid for employment”), or
● A recent letter from the SS office indicating that you have applied for a new SS card. The letter must contain your name
and SS number and cannot say “not valid for employment”. This should be replaced by a copy of the SS card at
re-contracting. If this printout is not available, you must provide the new copy of your SS card before contracting can be
completed.
2. Specific Client Information: If you intend to provide services to a specific individual, state his/her name here. If you are related
to the Client, state your relationship to the Client here. For example, if the client you are working for is your mother, your
relationship to the client is DAUGHTER or SON or CHILD.
3. Suitability: Individual Providers must complete and follow the directions contained in this section. If you have been suspended
or debarred from providing services under Medicare, Medicaid, Title XIX or Title XX programs you should have already been

HCS / AAA / DDA INDIVIDUAL PROVIDER CONTRACTOR INTAKE

DSHS 27-122 (REV. 02/2018)
 placed on the federal Office of Inspector General, Health and Human Services exclusions list. You can search excluded
individuals at http://exclusions.oig.hhs.gov/.aspx.
4. License Information. Complete this section as directed and include your driver’s license information if applicable.
Part B – State Employee Information (Mandatory for all Contractors). An Individual Provider is not a State Employee.
1. Current Washington State Employee: If you are employed by a state agency, university, college or community colleges, check
yes. School district employees, however, are not considered a Washington State employee.
2. Former Washington State Employee: If you were employed by a state agency, university, college or community colleges, check
yes. Former school district employees, however, would not be considered a Washington State employee.
3. Termination Date of Washington State Employment: List the last date employed by the agency.
4. If you answered YES to Question 1 OR your answer to Question 2 was YES and the date for Question 3 was within the last two
(2) years, you must complete and submit Part C of the Contractor Intake Form as well.
5. Certify information provided in this form (both Parts A and B) is accurate with your signature and date.
Part C – Ethics Certification for Current or Former State Employee
If you are a current or former Washington State employee, you must also complete the Ethics Certification form (Part C), sign and
date the bottom, and return it with Parts A and B of the completed Contractor Intake form.

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DSHS 27-122 (REV. 02/2018)
 HCS / AAA / DDA Individual Provider Contractor Intake
Part A: Contractor Specific Information
This is NOT a contract. Part A requires general information about the contractor. This form must be completed, signed and
submitted before any contract is offered.
1. Contractor Information
CONTRACTOR’S NAME (PLEASE PRINT CLEARLY) GENDER SOCIAL SECURITY NUMBER BIRTH DATE
LAST FIRST MI x  Male      535-88-2387 (MM/DD/YYYY)
Gorgas David L ☐
  Female  05/20/1966
IDENTIFICATION
   Unexpired State Driver’s License OR
☐ x Unexpired State Picture Identification OR ☐ Other (see 1.a.)
CONTRACTOR’S HOME ADDRESS CITY STATE ZIP CODE
     6004 McDougall Avenue Everett       WA    98203   
CONTRACTOR’S MAILING ADDRESS (PO BOX OR OTHER) CITY STATE ZIP CODE
                    
CONTRACTOR’S PHONE NUMBER (INCLUDE CONTRACTOR’S CELL PHONE NUMBER CONTRACTOR’S FAX NUMBER (INCLUDE
AREA CODE) (INCLUDE AREA CODE) AREA CODE)
   (425)750-3443      (425)750-3443        
PREFERRED PRIMARY LANGUAGE PREFERRED MEANS OF CONTACT E-MAIL ADDRESS
   English   ☐ Mail x Email      [email protected]
2. Specific Client
If you are completing this form to provide services for a specific person, please provide the following information:
NAME FAMILY MEMBER YOUR RELATIONSHIP TO CLIENT
     Benny Gamble ☐ Yes x No      
3. Suitability (Mandatory)
YES NO
a.   Have you had any State of Washington contract to provide services terminated for default? ☐ x
b. Have you had any professional license / certification / contract issued by the
State of Washington revoked or suspended (this does not include a driver’s license)? ☐ x
If yes, type of license / certification / contract:      
c. Have you ever had a substantiated finding of abuse, neglect, abandonment or exploitation
of a minor or vulnerable adult? ☐ x
d. Have you ever been convicted of any felony or criminal offense (felony or misdemeanor) or been
suspended or debarred from being a provider for Medicare, Medicaid, or Title XX service programs
since the beginning of those programs (as required by 42 CFR 455.106)? ☐ x
e. Do you currently have any charges pending for any felony or criminal offense (felony or misdemeanor)? ☐ x
If you answered “Yes” to any of the above, please attach a list with an explanation of the situation involved (include dates, type of
substantiated finding or crime and final disposition of charges).

4. License Information
  Are you licensed, certified or registered by any Washington State agency, including driver’s license? x Yes ☐ No
If yes, please complete the following:
TYPE OF LICENSE LICENSE NUMBER EXPIRATION DATE

   WA State Drivers License        WADL2STT5103B      05/20/2023

                 
                 
I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of information in the
Contractor Intake form is true and correct, and that I will notify DSHS of any changes.

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DSHS 27-122 (REV. 02/2018)
CONTRACTOR’S SIGNATURE DATE CONTRACTOR’S PRINTED NAME
     David L Gorgas 02/04/2021      David L Gorgas

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DSHS 27-122 (REV. 02/2018)
 HCS / AAA / DDA Individual Provider Contractor Intake
Part B: State Employee Information
This is NOT a contract.
Part B requires information specific to the contract you wish to enter.
You must check “Yes” or “No” to answer the following questions.
A contract cannot be issued without this information.

1. Are you a current Washington State employee or an employee of a State University or Community College?

● State University and Community College employees are considered Washington State employees.
● School District Employees are NOT considered State employees in this context.

● Individual Providers are NOT considered State Employees.

☐ Yes ☐ No

2. Have you ever been employed by the State of Washington?

☐ Yes ☐ No

3. If yes, what year did our employment terminate with the State of Washington?
  Date      
4. If your answer to Question 1 above was “Yes” or your answer to Question 2 was “Yes” and the date in Question 3 was within the
last two years, you must fill out Part C and return with Part A and B of this intake form.

I certify, under penalty of perjury as provided by the laws of the State of Washington, that all of the foregoing statements
are true and correct, and that I will notify DSHS of any changes in any statement.

CONTRACTOR’S SIGNATURE DATE

     
CONTRACTOR’S PRINTED NAME CONTRACTOR’S TITLE
           

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DSHS 27-122 (REV. 02/2018)
 HCS / AAA / DDA Individual Provider Contractor Intake
Part C: Ethics Certification for Current State Employees
This is NOT a contract. Part C requires information to avoid conflict with 42.52 RCW, Ethics in Public Service. A contract cannot be
issued without this information.
DSHS employees are prohibited from contracting as an Individual Provider for services to ALTSA and DDA clients, unless an
approval for outside employment has been granted, per Administrative Policy No. 18.18, Outside Employment. In the event that the
Contractor accepts employment with DSHS, the Contractor must immediately notify the DSHS Contact person listed on Page 1 of
this Contract, as well as the following:
● Director of the HCS Division, if you are providing services to a client of HCS or AAA; address is P.O. Box 45600, Olympia WA
98504-5600; and/or
● Deputy Assistant Secretary of DDA, if you are providing services to a client of DDA; address is P.O. Box 45310, Olympia WA
98504-45310.
CONTRACTOR’S NAME CURRENT STATE OFFICER / STATE EMPLOYEE NAME
           
TITLE OF YOUR STATE JOB CURRENT STATE EMPLOYER
           
I hereby certify that both of the following statements are true:
● I am a current state employee;

● My role as an individual provider is not in conflict with the proper discharge of my official duties as a state employee;
And one of the following is also true:
● I will not receive anything of economic value under the contract as defined in RCW 42.52.010 (20);
OR

● I have complied with RCW 42.52.030 (2);

OR
● I meet all of the following conditions:
o The contract is genuine and I will actually perform work under the contract.

o Performance of the contract is not within the course of my actual duties or under my direct supervision in my capacity
as a state officer or employee.
o Performance of the contract will not require me to reveal any confidential information or cause me to violate any state
agency rules pertaining to outside employment.

o The contract is neither performed for nor compensated by someone from whom I am prohibited from accepting a gift
(those prohibited gift givers include all persons who are regulated by DSHS).
o The contract is not one expressly created or authorized by me in my official capacity as a state officer or employee.

I certify, under penalty of perjury as provided by the laws of the State of Washington, that the statements made in this
Ethics Certification are true and correct and that I will notify DSHS of any changes.
CONTRACTOR’S SIGNATURE DATE
     
CONTRACTOR’S PRINTED NAME CONTRACTOR’S TITLE
           

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