Forms DD Billing Manual: This is a “living document,” and will continue to be treated as such. We will update and make changes to increase the validity and utilization of the billing manual. Please direct any comments to Lori Mota by email at [email protected]. Eligibility Form Application for Services Formulario De Solicitud De Servicios Inscricao Para Servicos Application for Assistance-Medicaid Waiver Have Medicaid or SSI Application Coversheet Blank Recertification CP-1 Eligibility Assessment Level of Care CP-12 Form Release of Information - Medical (DHS-25-M) Release of Information (DHS-25) Do not already have Medicaid Application Coversheet CP-1 Eligibility Assessment Level of Care CP-12 Form DHS-2 Application Release of Information - Medical (DHS-25-M) Release of Information (DHS-25) Finance Forms Finance Forms: Integrated Community Employment Reporting Form (ICE-RF) Spanish version Request to Change Respite Allocation Purchase Orders: PURCHASE ORDER VERSION 15 New Rate 7.1.2021 Home Health Agency Purchase Order Self-Direct Purchase Order Spanish version Transportation Forms: Self-Direct Reallocation for Transportation Form Request to Change Transportation Allocation Medical Forms Consultation/Referral Form Request for Petition for Instructions Financial Resources Rate Table Tier Packages: FY21 Annual Tier Package FY22 Annual Tier Package L9 Conversion Worksheet: FY22 L9 Conversion Worksheet New Rates Effective 7.1.2021 Provider Forms S106 Form S109 Form Quick Extension Form S109 and S106 HM fillable form Notification of BHDDH of IEP/CDP Meeting Residential Services Forms Shared Living Arrangement (SLA) Request Form Variance Forms Variance Submission and Review instructions Variance for Integrated Day Services Only Variance to Work in a Segregated Employment Setting Individualized Planning Tools ISP Addendum/Amendment Form - Please submit this form with any changes to a current ISP or PO. Interim ISP COVID-19 fillable form Emergency Data Form: Be sure to send any personal information through an encrypted or secure email Individual Service Plan Template Individual Service Plan Template Individual Service Plan Template 2 Individual Service Plan Template 2 Interim Individual Service Plan ISP Attachment Form ISP Attachment Form Plan Combinado 1 Info Briefs InfoBrief: Use of Day Funds PDF file, less than 1mbmegabytes InfoBrief: Utilizar Fondos (en espanol) PDF file, less than 1mbmegabytes InfoBrief: Adaptive Communication PDF file, less than 1mbmegabytes InfoBrief: Employment PDF file, less than 1mbmegabytes InfoBrief: Retirement and Variances PDF file, less than 1mbmegabytes InfoBrief Goods and Services.pdf PDF file, less than 1mbmegabytes InfoBrief New Customized Employment Project 10-22-20 PDF file, less than 1mbmegabytes Note: Adobe Reader To fill-in a PDF application on your computer, you will need Adobe Reader software installed on your computer. There is no cost to install Adobe Reader and is available here. You may also print the application, fill it out and mail to the BHDDH, Division of Developmental Disabilities, 6 Harrington Hall, Cranston, RI 02920.