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Form NumberForm NameEffective DatePDFWord
DD-023-FF Application for Eligibility Determination 07/01/2008 58kbs
DD-023-FFS Application for Eligibility Determination (Spanish) 07/01/2008 59kbs
DD-024 Developmental Foster Home Progress Report 12/01/2006 84KBS
DD-090-FF DDD Billing Information 10/01/2009 82 KB
DD-097-1-FF Pre-Service Provider Orientation 09/01/2012 176 KB
DD-097-1-FFS Orientación Previa al Servicios para Proveedores 09/01/2012 186 KB
DD-099-A-FF Pre-PAS Screening Tool Ages 7 Months Through 2 Years 09/01/2006 38kbs
DD-099-B-FF Pre-PAS Screening Tool Ages 3 Through 5 Years 09/01/2006 38kbs
DD-099-C-FF Pre-PAS Screening Tool Ages 6 Through 11 Years 09/01/2006 38kbs
DD-099-D-FF Pre-PAS Screening Tool Ages 12 and Older 09/01/2006 38kbs
DD-099-FF Pre-PAS Screening Tol Ages 0 Through 6 Months 09/01/2006 37kbs
DD-162-PD Consent for Use of Behavior-Modifying Medications with a Behavior Treatment Plan 06/01/2006 32KBS
DD-191-FF Incident Report 05/01/2014 76 KB
DD-208-FF Community Living Services (CLS) Application and Agreement 04/01/2012 116 KB
DD-208-FFS Solicitud y Convenio para los Servicios para la Vida en Comunidad (CLS por sus siglas en inglés) 04/01/2012 131 KB
DD-211-FF Home Modifications Services Request 09/01/2014 71 KB
DD-224-FF Changes in the ISP 01/01/2014 53 KB
DD-224-FFS Cambios en el Plan ISP 01/01/2014 55 KB
DD-254 Fire Risk profile 07/01/2003 179KBS 74KBS
DD-301-FF Augmentative Communication Assessment Referral Checklist 08/01/2013 61 KB
DD-308 Individual Emergency Information - Residential 12/01/2004 45KBS 88KBS
DD-390 ISP Strategy 09/01/2011 38 KB
DD-390-A Data Record 04/01/1997 36KBS
DD-403 Reference Request 12/01/2005 29KBS 61KBS
DD-403 S Reference Request (Spanish) 12/01/2005 29KBS 69KBS
DD-417-1 Behavior Modifying Medication Review (Page 1) 08/01/2006 17KBS
DD-417-2 Behavior Modifying Medication Review (Page 2) 08/01/2006 8KBS
DD-417-3 Behavior Modifying Medication Review (Page 3) 08/01/2006 12KBS
DD-522-FF DDD Intake Record 08/01/2010 45kbs
DD-524-FF Authorization for Release of Information 02/01/2012 47 KB
DD-524-FFS Autorización para Entregar Información 02/01/2012 52 KB
DD-525 S Intake Application - 3 Years and Older (Spanish) 06/01/2007 492KBS 291KBS
DD-640 Eligibility Criteria 03/01/2012 82 KB
DD-640-S Elegibilidad 03/01/2012 74 KB
DDD Billing DDD Billing Document Template 09/02/2009 732kbs
DDD-1006A Resignation Notice 08/01/1998 9KBS
DDD-1054A Notice Of Inspection Rights-Disclosure Verification 01/01/1999 22KBS
DDD-1088A Client Services Trust Fund 05/01/2008 176KBS
DDD-1088A Client Services Trust Fund (Spanish) 05/01/2008 177KBS
DDD-1150A Augmentative Communication Assessment Pre-Evaluation Information (English) 12/01/2004 153KBS
DDD-1150A-S Estimación para Incremento de Comunicación Información para la Preevaluación 12/01/2004 157 KB
DDD-1151A Communication Skills Questionnaire 03/01/2015 242 KB
DDD-1164A Attendant Care Progress Notes 02/01/2007 18KBS
DDD-1215A Adaptation Station 07/01/2013 403 KB
DDD-1215AS La Estación para Adaptaciones 07/01/2013 399 KB
DDD-1257A Discharge/Transition Checklist 12/01/2005 2024KBS 54KBS
DDD-1258A Emergency Contact Plan 02/01/2006 218KBS 68KBS
DDD-1270A ISP Checklist 05/01/2007 213KBS 61KBS
DDD-1270A S ISP Checklist (Spanish) 05/01/2007 155KBS 66KBS
DDD-1271A Continuation Page 12/01/2005 239KBS 31KBS
DDD-1271A S Continuation Page (Spanish) 12/01/2005 188KBS 34KBS
DDD-1328A Referral to Vocational Rehabilitation 07/01/2013 82 KB
DDD-1332A Individual Support Plan/Individualized Family Service Plan/Individual Attributes Checklist 09/01/2007 186KBS 199KBS
DDD-1345A Medical Justification for Home Modifications 09/01/2014 53 KB
DDD-1360A Team Assignment Tracking 01/01/2005 24KBS 59KBS
DDD-1369A Request for Translation 05/01/2006 402kbs
DDD-1370A Child Information Guide 07/01/2008 287KBS
DDD-1370A Child Information Guide (Spanish) 07/01/2008 309KBS
DDD-1390A Human Rights Committee Volunteer Application 01/01/2015 54 KB
DDD-1401A Monthly Progress Report 12/01/2007 205KBS 58KBS
DDD-1401B Six-Month Report 12/01/2007 192KBS 96KBS
DDD-1401C Quality assurance Review 12/01/2007 200KBS 102KBS
DDD-1401D Quality Assurance Review Summary 12/01/2006 169KBS 55KBS
DDD-1402A Monthly Progress Report 12/01/2006 226KBS 71KBS
DDD-1402B Six-Month Report 12/01/2006 204KBS 120KBS
DDD-1402C Quality Assurance Review 12/01/2006 199KBS 128KBS
DDD-1402D Quality Assurance Review Summary 12/01/2006 172KBS 59KBS
DDD-1403A Monthly Progress Report 12/01/2006 233KBS 168KBS
DDD-1403B Six-Month Report 12/01/2006 223KBS 120KBS
DDD-1403C Quality Assurance Review 12/01/2006 227KBS 120KBS
DDD-1403D Quality Assurance Review Summary 12/01/2006 174KBS 58KBS
DDD-1403E Job Coach Agreement 12/01/2006 204KBS 98KBS
DDD-1403F Job Search Agreement 12/01/2006 205KBS 88KBS
DDD-1404A Monthly Progress Report 12/01/2006 237KBS 116KBS
DDD-1404B Six-Month Report 12/01/2006 207KBS 129KBS
DDD-1404D Quality Assurance Review Summary 12/01/2006 172KBS 58KBS
DDD-1404E Employment Support and Agreement 12/01/2006 267KBS 91KBS
DDD-1426A Diaper/Brief Request for Consumers Ages 3-21 03/01/2007 243KBS 117KBS
DDD-1431A Attendant Care/Housekeeping Service/Monitoring/Supervision 04/01/2007 233KBS 71KBS
DDD-1432A Critical Service Gap Report 06/01/2010 115kbs
DDD-1432A-LP Critical Service Gap Report 06/01/2010 56 KB
DDD-1432A-SLP Informe de Interrupción en Servicios Críticos 06/01/2010 52 KB
DDD-1432AS Critical Service Gap Report (Spanish) 06/01/2010 144kbs
DDD-1469A Spouse Attendant Care Acknowledgment of Understanding 09/01/2009 188kbs
DDD-1469AS Spouse Attendant Care Acknowledgment of Understanding (Spanish) 07/01/2009 198kbs
DDD-1472A ISP - Annual Review and Update Packet (At Home Adult) 10/01/2014 1092 KB
DDD-1472A-S ISP - Paquete del Repaso Anual y Actualización del ISP (Adulto en el hogar) 10/01/2014 1181 KB
DDD-1472B ISP - Annual Review and Update Packet (Residential) 10/01/2014 674 KB
DDD-1472B-S ISP - Paquete del Repaso Anual y Actualización del ISP (La colocación residencial) 10/01/2014 736 KB
DDD-1472C ISP - Annual Review and Update Packet (At Home Child) 10/01/2014 1050 KB
DDD-1472C-S ISP - Paquete del Repaso Anual y Actualización del ISP (Menor en el hogar) 10/01/2014 1127 KB
DDD-1472D ISP - Annual Review and Update Packet (Targeted/DD Only - Age 3 and Above) 02/01/2014 319 KB
DDD-1472D-S ISP - Paquete del Repaso Anual y Actualización del ISP (Enfocado/Sólo para DD - 3 años y más de edad) 02/01/2014 359 KB
DDD-1474A Division Offices List 03/01/2015 86 KB
DDD-1482A Do Your Business a Favor...Hire a Person with a Disability 05/01/2008 111KBS
DDD-1505A Seizure Record 05/01/2009 203kbs
DDD-1526A Claims Grievance Log 05/01/2010 276kbs
DDD-1532A Hardship Reduction Request 02/01/2015 64 KB
DDD-1532A-S Solicitud de Reducción Debido a Dificultad Económica 02/01/2015 68 KB
DDD-1551A Medallion Program - Order Form 06/01/2011 154kbs
DDD-1551AS Medallion Program Order Form (Spanish) 06/01/2011 161kbs
DDD-1580A Reversal Adjustment Cover Sheet 12/01/2014 40 KB
DDD-1580B Reversal Adjustment Claims Request 12/01/2014 38 KB
DDD-1590A Monthly Invoice Cover Sheet 07/01/2012 46 KB
DDD-1603A Consent/Authorization for Use of Photo, Video Tape, Story or Other 11/01/2012 42 KB
DDD-1603AS Consentimiento y Autorización para el Uso de Fotos, Videos, Historias u Otros 11/01/2012 73 KB
DDD-1620A Home Modification Services-Landlord/Property Owner Authorization 03/01/2015 54 KB
DDD-1620A-S Servicios para Modificación del Hogar Autorización del Arrendador o Propietario 03/01/2015 57 KB
DDD-1626A ALTCS Service Model Options (Decision Tree) 08/01/2014 65 KB
DDD-1626A-S Opciones del Modelo de Servicio del ALTCS (Árbol de decisión) 08/01/2014 66 KB
DDD-1640A Separation of Children and Adults in Center Based Programs 03/01/2014 45 KB
DDD-1651A COBV Waiver Request 04/01/2014 137 KB
DDD-1658A Agency With Choice: Individual Representative 08/01/2014 42 KB
DDD-1658A-S Agency With Choice: Representante Individual 08/01/2014 41 KB
DDD-1659A Agency With Choice: Partnership Agreement 08/01/2014 85 KB
DDD-1659A-S Agency With Choice: Acuerdo de Colaboración 08/01/2014 81 KB
DDD-1660A Disclosure of Ownership/Control and Criminal Offenses Statement (w/attachment A) 04/01/2014 182 KB
DDD-1661A American Indian Health Plan - Equipment and Supplies Prior Authorization 05/01/2014 76 KB
DDD-1661B Prior Authorization 03/01/2015 77 KB
DDD-1662A American Indian Health Plan - Equipment and Supplies Changes/Additions Prior Authorization 05/01/2014 88 KB
DDD-1673A Agency with Choice (AWC) Provider Training Request 10/01/2014 41 KB
DES-1076A Request for Search of Central Registry for Background Check 01/01/2015 294 KB
DES-1076AS Solicitud para la Búsqueda en el Registro Central con Objetivo de Verificar Antecedentes 01/01/2015 326 KB
LCR-1025A Application for Initial HCBS Certification 01/01/2015 81 KB
LCR-1025A-S Solicitud para Certificación Inicial de HCBS 01/01/2015 92 KB
Rate Assessment form Rate Assessment form 11/07/2008 263KBS
Rate Assessment Instructions Rate Assessment Instructions 11/07/2008 23KBS
Uniform Billing Document Uniform Billing Document (Short form) 12/17/2008 23KBS


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