Forms
For Staff, Families, SCEs, and Providers
You will need to download the forms and use Adobe Acrobat to open them for some of the features of these forms to work properly. Please reference the Troubleshooting the interactive PDF features of the forms document for help navigating the interactive form features.
Caregiver compensation forms
- Caregiver Compensation Annual Authorization Form CC-003opens in a new tab
- Visit the Caregiver Compensation page to view forms for families and individuals
Self-administered services (SAS) forms
- Self-Administered Services Review Checklistopens in a new tab
- Quarterly Timesheet Review opens in a new tab
- Visit the Self-Administered Services (SAS) page to access SAS forms for families and individuals
Other forms for SCEs and providers
- 1-2 Authorization to Furnish Informationopens in a new tab
- 295 CAPS Form – One-Time Payment Formopens in a new tab
- 928 Exceptional Needs Prior Authorization for Residential Habilitation opens in a new tab
- Employee Medicaid Disclosureopens in a new tab
- DSPD Civil Commitment Referralopens in a new tab
- Group Services Review Request Formopens in a new tab
- Request for Additional Employment Preparation Services (EPR)opens in a new tab
- Host Home Certification Requirementsopens in a new tab
- CIE - Milestones Payment Request Formopens in a new tab
- CIE - Individualized strenghts-based discovery assessment formopens in a new tab
- CIE - Vocational Assessment
Other general forms (DSPD)
- 3-1 Application for Physical Disabilities Services opens in a new tab
- 3-2 Critical Needs Assessment for Physical Disabilities Services opens in a new tab
- 3-3 PDW Parents as Providers opens in a new tab
- 18 Request for ICD-10 Code From A Diagnosing Professional opens in a new tab
- 818 Choice of Service System CSW Waiver opens in a new tab
- 818 Choice of Service System CSW Waiver (Spanish) opens in a new tab
- 818B Choice of Service System ABI Waiver opens in a new tab
- 818B Choice of Service System ABI Waiver (Spanish) opens in a new tab
- 818C Choice of Service System LSW Waiver opens in a new tab
- 818C Choice of Service System LSW Waiver (Spanish) opens in a new tab
- 818D Choice of Service System CTW Waiver opens in a new tab
- 818D Choice of Service System CTW Waiver (Spanish) opens in a new tab
- 824I Social History opens in a new tab
- 843B Case Transfer Information opens in a new tab
- 929 Respite – Intensive Screening opens in a new tab
- 930 Enhanced Staffing opens in a new tab
- GRAMA Request for Records opens in a new tab
- Paid staff training opportunity request form opens in a new tab
Regardless of the model of delivery (Provider or SAS) all background screening applicants are now being submitted using one standardized application. The application for background screening can be accessed by following the link below:
- HIPAA - Notice of Privacy Practices opens in a new tab
- HIPAA - Information Request Form opens in a new tab
- HIPAA - Request for Restricted Use and Disclosure opens in a new tab
- HIPAA - Request for Accounting Disclosure opens in a new tab
- HIPAA - Request for Amendment of Health Records opens in a new tab
- HIPAA - Authorization to Disclose Protected Health Information opens in a new tab