DDS Forms

Form NumberForm TitleCategory
DS 223Family Home Agency Program (FHA) Criminal Background Action FormFHA
DS 6014Criminal Record StatementVendor/Provider
DS 229Self-Determination Program (SDP) Criminal Background Action FormSDP
DS 6010Annual Family Program Fee Payment Form - EnglishConsumer/Families
DS 6010 (Vietnamese)Annual Family Program Fee Payment Form (Vietnamese)Consumer/Families
DS 6010 (Tagalog)Annual Family Program Fee Payment Form (Tagalog)Consumer/Families
DS 6010 (Spanish)Annual Family Program Fee Payment Form (Spanish)Consumer/Families
DS 6010 (Russian)Annual Family Program Fee Payment Form (Russian)Consumer/Families
DS 6010 (Chinese Traditional)Annual Family Program Fee Payment Form (Chinese Traditional)Consumer/Families
DS 6009Annual Family Program Fee Registration Form - EnglishConsumer/Families
DS 6011 (Vietnamese)Annual Family Program Fee Payment Form, Second Notice (Vietnamese)Consumer/Families
DS 6011 (Tagalog)Annual Family Program Fee Payment Form, Second Notice (Tagalog)Consumer/Families
DS 6011 (Spanish)Annual Family Program Fee Payment Form, Second Notice (Spanish)Consumer/Families
DS 6011 (Russian)Annual Family Program Fee Payment Form, Second Notice (Russian)Consumer/Families
DS 6011 (Chinese Traditional)Annual Family Program Fee Payment Form, Second Notice (Chinese Traditional)Consumer/Families
DS 6011Annual Family Program Fee Payment Form, Second NoticeConsumer/Families
DS P304 (Spanish)Rights of Individuals with Developmental Disabilities (Spanish)Complaint
DS P304Rights of Individuals with Developmental DisabilitiesComplaint
DS 6028Community Crisis Home - Rate Development Individual Costs Associated with TransitionVendor/Provider
DS 6024Rate Development - Individual Costs Associated with ResidencyVendor/Provider
DS 6023Rate Development-Facility CostsVendor/Provider
DS 6022 (Spanish)Language Access Complaint Form (Spanish)General
DS 6022Language Access Complaint FormGeneral
DS 6017Authorization for Release of Information, Photographs or Recordings for Communication or Media-Relation PurposesGeneral
DS 6016Conflict of Interest Reporting StatementGeneral
DS 6015Criminal History Statement Vendor/Provider
DS 5862 (Vietnamese)Parental Verification for Receipt of Behavioral Services (Vietnamese)Consumer/Families
DS 5862 (Tagalog)Parental Verification for Receipt of Behavioral Services (Tagalog)Consumer/Families
DS 5862 (Spanish)Parental Verification for Receipt of Behavioral Services (Spanish)Consumer/Families
DS 5862 (Russian)Parental Verification for Receipt of Behavioral Services (Russian)Consumer/Families
DS 5862 (Chinese Traditional)Parental Verification for Receipt of Behavioral Services (Chinese Traditional)Consumer/Families
DS 5862Parental Verification for Receipt of Behavioral ServicesConsumer/Families
DS 5856A (Spanish)Notice of Privacy PraCtices (ICF/DD SPA Program) (Spanish)Vendor/Provider
DS 5856ANotice of Privacy Practices (ICF/DD SPA Program)Vendor/Provider
DS 5651Consent to Release Information & ImagesGeneral
DS 3770Medicaid Waiver Eligibility RecordRegional Center
DS 2201 (Spanish)Home and Community Based Services Waiver Consumer Standardized Annual Review (Spanish)Vendor/Provider
DS 2201Home and Community Based Services Waiver Consumer Standardized Annual ReviewVendor/Provider
DS 2200Medicaid Waiver Consumer Choice of Services/Living Arrangement StatementGeneral
DS 2007 (Spanish)Citizen Comments and Complaints (Spanish)General
DS 2007Citizen Comments and ComplaintsVendor/Provider
DS 1971WAP - WAP/Work Activity Program Consumer Monthly ReportVendor/Provider
DS 1969Vocational Services Exit ProgramVendor/Provider
DS 1968Vocational Rehabilitation ReferralVendor/Provider
DS 1967Request for Rate Adjustment - Staff ChangeVendor/Provider
DS 1966Request for Rate Adjustment - Occupancy ChangeVendor/Provider
DS 1964 LargeSupported Employment Group Billing and Attendance Form (Rate $36.57)Vendor/Provider
DS 1964 LargeSupported Employment Group Billing and Attendance Form (Rate $39.57)Vendor/Provider
DS 1963Request for Approval of SEP Groups ChangesVendor/Provider
DS 1962Supplemental Narrative Summary Guidance TemplateVendor/Provider
DS 1962Request for new SEP GroupsVendor/Provider
DS 1961WAP - WAP/Individual Habilitation Services PlanVendor/Provider
DS 1950Habilitation Services Cost Statement Forms (w/out Formulas)Vendor/Provider
DS 1950Habilitation Services Cost Statement Forms (w/Formulas)Vendor/Provider
DS 1897Bin-Home Respite Cost StatementVendor/Provider
DS 1897Community-Based Day Program Cost StatementVendor/Provider
DS 1891 (Spanish)Applicant/Vendor Disclosure Statement (Spanish)Vendor/Provider
DS 1891Applicant/Vendor Disclosure StatementVendor/Provider
DS 1890 (Spanish)Vendor Application Form (Spanish)Vendor/Provider
DS 1890Vendor Application FormVendor/Provider
DS 1853Training Program for ICF/DD-N AttendantVendor/Provider
DS 1852Health Facility Program Plan ApplicationVendor/Provider
DS 1851Specialized Procedures Request Cover SheetVendor/Provider
DS 1827 (Spanish)Early Start Compliant Investigation Request (Spanish)Early Start
DS 1827Early Start Compliant Investigation RequestEarly Start
DS 1811 (Spanish)Respite Services Billing Form (Spanish)Vendor
DS 1811Respite Services Billing FormVendor
DS 1808 (Spanish)Mediation Conference Request (Spanish)Early Start
DS 1808Mediation Conference RequestEarly Start
DS 1805 (Spanish)Fair Hearing Request (Spanish)Fair Hearing
DS 1805Fair Hearing RequestFair Hearing
DS 1804 (Spanish)Notification of Resolution (Spanish)Fair Hearing
DS 1804Notification of ResolutionFair Hearing
DS 1803 (Spanish)Notice of Proposed Action (Spanish)Fair Hearing
DS 1803Notice of Proposed ActionFair Hearing
DS 1802 (Spanish)Due Process Hearing Request (Spanish)Early Start
DS 1802Due Process Hearing RequestEarly Start
DS 1235A (Spanish)Family Financial Statement (Spanish)Parental Fee
DS 1235AFamily Financial StatementParental Fee
DS 1214 (Spanish)Parental Fee Program Home Leave Credits (Spanish)Parental Fee
DS 1214Parental Fee Program Home Leave CreditsParental Fee
DS 306Denial of Rights ReportComplaint
DS 255 (Spanish)Welfare and Institution Code Section 4731 Compliant Form Investigation Request (Spanish)Complaint
DS 255Welfare and Institution Code Section 4731 Compliant Form Investigation RequestComplaint
DS 254 (Spanish)Consumer Advisory Committee Membership Application (Spanish)Consumer
DS 254Consumer Advisory Committee Membership ApplicationConsumer
DS 228Applicant Information ReleaseOPS
DS 202Request for OPS Investigative ReportOPS
DS 43 (Spanish)Request to Inspect Public Records (Spanish)PRA
DS 43Request to Inspect Public RecordsPRA
DS 2Transportation Cost StatementServices
DS 6009 (Spanish)Annual Family Program Fee Registration Form (Spanish)Consumer/Families

Last modified: June 3, 2019