Information, Forms, And Resources For DDA Providers
All forms marked with .pdf 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.
- DDA Provider Renewal License Application Forms
- 1st Quarter Vacancy Data
- 1st Quarter Vacancy Data Memo
- CMS 1500 Form
- CMS 1500 Form Instructions
- Tamper Proof Prescription Fact Sheet
- Certification Regarding Environment Tobacco Smoke
- Vendor Electronic Fund Transfer
- U. S Department Of Health And Human Services Certification Regarding Lobbying
- Certification Regarding Debarment, Suspension, and other Responsibility Matters
- 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)
- Cost Detail Sheet Supported Employment (Part V: Section A)
- Instructions for Part V Cost Detail Sheets for Day and Supported Employment
- Monthly Contribution to Room And Board (Fee Form) Documents
- 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.