• Forms For Providers
• Policy on Reportable Incidents And Investigations
• Staff Retention & Development Toolbox
• Provider Consumer Information System (PCIS2)
• National Provider Identifiers
• Disaster Readiness Planning Template
• Ask Me! FY05 Report
• Ask Me! FY06 Report
• Ask Me! FY07 Report
• Becoming A DDA Provider
• Training
• Regulations
• Licensing Information - Office of Health Care Quality

Forms For Providers

 All forms marked with are in PDF. (The freely available Adobe Acrobat reader is required to view and print PDF files).

Please Note: To download/save any file to your hard drive, right click on the link and click on save target as... from the drop down menu to save the file to your hard drive.

• Application Forms For Services
• New Directions Forms
• 1st Quarter Vacancy Data
• 1st Quarter Vacancy Data Memo
• CMS 1500 Form
• CMS 1500 Form Instructions
• Provider Agreement
  • Rate Based Provider Agreement
  • FSS, IFC and ISS Provider Agreement
• FY08 Rates
• FY07 Rates
• OTO Invoices
  • OTO Invoices - FPS/CSLA
  • OTO Invoices - FSS, IFC and ISS
  • OTO Invoices Instructions
• Supplemental Services Invoices
• Supplemental Payment Request Procedure
• DDA Procurement Exemption
  • DDA 432 Summary Exempt Format (Excel File)
  • DDA 432 Summary Non-Exempt Format (Excel File)
  • DDA 432 A-H Non-Exempt (Excel File)
  • DDA 432 A-H Exempt (Excel File)
  • DDA 437 Form (Excel File)
  • DDA 438 Form (Excel File)
  • DDA 440 Form (Excel File)
  • DHMH 433 Form
  • DHMH 434 Form
  • Roster Form (Excel File)
• Certification Regarding Environment Tobacco Smoke (Word file)
• Vendor Electronic Fund Transfer
• U. S Department Of Health And Human Services Certification Regarding Lobbying (Word file)
• Certification Regarding Debarment, Suspension, and other Responsibility Matters (Word file)
• 2007 Annual Wage Survey (Excel file)
• 2007 Annual Wage Survey Memo
• Wage Survey Attestations
• FY07 Cost Report And Instructions
  • 2007 DDA Cost Report (Excel File)
  • Cost Report instructions
  • Cost Report Memo
  • Cost Report Attestation Sample - Individual
  • Cost Report Attestation Sample - Total
• Individual Indicator Rating Scale
• Service Funding Plan Documents
  • Service Funding Plan Instruction
  • Service Funding Plan
  • Cost Detail Sheet Residential; CSLA; ISS; FSS; ISP (Part V: Section A)
  • Cost Detail Sheet Day (Part V: Section A) (Excel File)
  • Cost Detail Sheet Supported Employment (Part V: Section A) (Excel File)
  • Instructions for Part V Cost Detail Sheets for Day and Supported Employment
• Rolling Access
  • Rolling Access Quarterly Report (Excel file)
  • Instructions
• Monthly Contribution to Room And Board (Fee Form) Documents
  • Monthly Contribution to Room and Board and Cost of Care
  • Monthly Contribution to Room and Board and Cost of Care Instructions
• OHCDS application
• PCIS2 Licensed Provider Logon Request Form
• Provider Agency Information Request Sheet
  In order to be listed or change the information about your agency on the DDA Web site, please complete this form. Mail the form along with a cover letter (on agency letterhead) asking DDA to include your information on the Web site. Please address the cover letter to Mr. Pete deFries, Assistant Director Operations, at DDA HQ (201 W. Preston Street, Fourth Floor, Baltimore, MD 21201).
  The cover letter must be signed by the Executive Director. The Executive Director will receive a reply letter when the information has been added to the Web site. It usually takes about 1-2 weeks for the information to be placed on the Web site.

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Policy On Reportable Incidents And Investigations

Some files are in PDF. (The freely available Adobe Acrobat reader is required to view and print PDF files.)
Please right click on any link and click on save target as... from the drop down menu to save any file to your hard drive.

• Policy on Reportable Incidents
• Appendix 3/3A
• Appendix 4 (Microsoft Word)
• Appendix 5 (Microsoft Word)
• Appendix 6
• Appendix 7 (Microsoft Word)
• Appendix 7 Addendum (Microsoft Word)

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