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Application Forms

Section 164-d of the Executive Law requires that every state agency shall make the various application forms developed and distributed by such agency for public use that are readily convertible to internet form and are intended to be used by the general public available on the internet. The forms listed below have been identified by OMRDD as meeting the requirements of the law.

OMRDD will begin the process of updating this listing in February, 2009. If any additional forms are identified that should be posted, the name(s) of the form(s) and a corresponding date for posting will be listed in this section. If you have questions regarding this page or any of the forms posted herein, please email the OMRDD Webmaster.

This listing will be updated as necessary but, at the minimum, at least once per year.

Application for Certification -LS 22- (Family Care Home provider)

Certificate of Need (CON)

Consumer Application for Participation in Medicaid Service Coordination

User ID and System Access Request Form - request a user account for the OMRDD Secure Site Applications.

CAB Informed Consent

CAB Informed Consent Submission Checklist(fillable form)

Dental Consent Overview(fillable form)

Medical Consent Overview (fillable form)

Criminal History Record Check

Criminal History Record Checks requirements, which are effective April 1, 2005, apply to prospective employees and volunteers, as well as family care providers and others involved with family care.

Request for Criminal History Record Check Form

Developmental Disabilities Profile Forms

DDP-1 Form*. - Printable Developmental Disabilities Profile Registration/Movement form. Use this form to report additions to and removals from programs. Please see the Users' Guide for more detailed instructions.

DDP-2 Form*. - Printable Developmental Disabilities Profile form. Use this form to describe individuals who have been added to a program and at least once every two years for individuals receiving services. Please see the Users' Guide for more detailed instructions.

DDP-4 - Confidential Needs Identification

Health Care Adjustment

Health Care Adjustment Information
Information on Health Care Adjustment IV & V; HCE I, II & III Simplification; and HCE I, II & III Overpayments.

HCE I, II & III Self Disclosure Form   Instructions
The form and instructions used to calculate recovery amounts for unused HCE I, II and/or III funds due to OMRDD and instructions on how to submit the recoveries.

Health Care Adjustment IV & V Employer Health Care Premium Worksheet
This form should be used to determine the amount of HCA IV & V funds that must be applied to employer paid health care premium increases. This form does not need to be submitted, but for audit purpose, it should be kept on file by provider.

Options for People Through Services (OPTS) Forms

OPTS IRA Enrollment Form . - To be completed by the OPTS Provider and submitted to the local DDSO, or NYCRO for services provided in New York City, for certified residences where Residential Habilitation is funded through an OPTS Agreement. See Instructions.

OPTS NON-IRA Enrollment Form . - To be completed by the OPTS Provider and submitted to the local DDSO, or NYCRO for services provided in New York City, for OPTS services other than IRA Residential Habilitation funded through an OPTS Agreement.   See Instructions.

OPTS EARNINGS/VESID Enrollment Form - To be completed by the OPTS Provider and submitted to the local DDSO, or NYCRO for services provided in New York City, for OPTS services.   See Instructions

Pre-Eligibility Form

Eligibility for OMRDD Services - Important Facts

Transmittal for Determination of Developmental Disability Form . This verification of an individual's qualifying developmental disability is required for determination of eligibility for OMRDD services. The form is also available in Microsoft Word  - Fillable Version.     See Instructions.

 

OMRDD does not have a priority list for posting additional application forms. Next review: May, 2010

Additional Forms

Authorization/Consent for Use or Disclosure of Clinical Information

Authorization/Consent for Use or Disclosure of Information for Publication Purposes Form Fillable, effective August 2005. The form is also available in Microsoft Word Fillable.

Central Operations - Payment Processing Unit Billing Forms and Instructions

Home and Community Based Services (HCBS) Waiver Service Documentation Forms.

Incident Reporting Forms.

Level of Care Eligibility Determination Form

Liability Notices

Medication Administration Course Certificate/Recertification Record  PDF version

MSC - Medicaid Service Coordination Forms. - For service coordinators and administrative staff of vendors that provide Medicaid Service Coordination (MSC) services under contract with the OMRDD.

Ready to go Form - Form to provide essential medical information in an emergency.

Shared Secret Hint Procedure - A new procedure implemented in an effort to ensure security in the event a Provider Agency user’s password needs to be reset quickly due to time constraints.

Training Manual Order Forms

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Forms are only available in PDF file format (PDF format allows you to view your form electronically on most computers. The freely available Adobe Acrobat Reader is required to view and print the PDF files). If you cannot access the forms, they are available by contacting your local DDSO.