Dshs 10 301 PDF Details

When individuals or their family members interact with the Developmental Disabilities Administration (DDA), understanding the procedures and documentation required is crucial for ensuring continued support and services. The DSHS 10-301 form serves as a critical notification vehicle, informing clients about the need for an eligibility review. Situations necessitating this review include instances where the individual has been diagnosed with conditions such as Intellectual Disability, Cerebral Palsy, Epilepsy, Autism, or another Neurological or Other Condition Similar to Intellectual Disability. The form highlights the importance of providing updated information to affirm eligibility under these categories. It outlines a process where clients or their representatives are asked to provide consent for DDA to obtain necessary documentation from identified health care providers. The form does so by incorporating a Required Documentation Table, guiding what specific information is required and from whom it must be gathered. Failure to respond or provide adequate documentation could result in the termination of eligibility, underscoring the importance of timely and complete submissions. To assist in this process, the form also includes contact information for DDA representatives who can offer additional guidance and clarification, ensuring that clients and their families have access to needed support throughout this review process.

QuestionAnswer
Form NameDshs 10 301
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfood stamp review online, where do you send eligibility review form for dshs for the state of washington, dshs online, dshs online application

Form Preview Example

DEVELOPMENTAL DISABILITIES ADMINISTRATION (DDA)

Notification of Eligibility Review

DATE:

CLIENT NAME AND ADDRESS

CLIENT REPRESENTATIVE NAME AND ADDRESS

RE: NOTIFICATION OF ELIGIBILITY REVIEW FOR

You are currently a client with the Developmental Disabilities Administration (DDA). DDA Eligibility rules require a review of eligibility at various times. We need more information to continue your eligibility for DDA under one of the following conditions: Intellectual Disability, Cerebral Palsy, Epilepsy, Autism, or Another Neurological or Other Condition Similar to Intellectual Disability. We have attached the Required Documentation Table to let you know what information is needed.

What do you need to do?

DDA will be glad to send for the information needed for this re-determination. If you want DDA to send for this information, please complete the attached consent form as follows:

1.Indicate on the consent form which places, providers and facilities we may request information from including contact information;

2.Sign the enclosed consent form(s); and

3.Return it to DDA in the enclosed addressed envelope.

What happens if I do not respond to this request?

 

If we do not hear from you, we will review your eligibility using the information we have available to us in your client

 

file. If there is not sufficient information to confirm the eligibility decision, then your eligibility for DDA will be

 

terminated.

 

Respond as soon as possible to avoid any disruption in service, but no later than

 

.

If we do not hear from you by this date, we will make an eligibility determination based on information in your file.

 

If you have any questions contact:

 

NAME

 

TELEPHONE NUMBER

 

E-MAIL ADDRESS

A copy of the state rules governing eligibility (WAC 388-823) is available upon request or online at https://www.dshs.wa.gov/dda/consumers-and-families/eligibility.

Enclosures: Required Documentation Table

Consent form (DSHS 14-012)

cc: Client file

DSHS 10-301 (REV. 10/2021)

Required Documentation Table

DISABILITY CONDITION

 

DIAGNOSIS

DIAGNOSTICIAN

OTHER RECORDS

Intellectual Disability

 

Intellectual Disability

A Licensed Psychologist, Washington

Full Psychological report including a Full Scale IQ score of more

 

 

 

Certified School Psychologist or other

than two standard deviations below the mean and adaptive skills

 

 

 

school psychologist certified by the

test score of more than two standard deviations below the mean

 

 

 

National Assoc. of School

completed within the last 36 months.

 

 

 

Psychologists

 

 

 

 

 

 

Cerebral Palsy

 

Cerebral Palsy

Licensed Physician

Onset prior to age three (3) and information supporting the need

 

 

Quadriplegia

 

for daily direct physical assistance in two or more areas

 

 

Hemiplegia

 

(toileting, bathing, eating, dressing, mobility, or communication).

 

 

 

 

 

 

Diplegia

 

 

 

 

 

 

 

Epilepsy

 

Epilepsy or

Board Certified Neurologist

Diagnosis based on medical history and neurological testing,

 

 

Seizure disorder

 

confirmation from physician or neurologist of uncontrolled and

 

 

 

 

ongoing or recurring seizures, and adaptive skills test showing

 

 

 

 

substantial limitations in adaptive functioning of more than two

 

 

 

 

standard deviations below the mean.

 

 

 

 

 

Autism

 

Autism or Autistic Disorder

A Licensed Psychologist, a Licensed

Full evaluation per DSM-IV-TR meeting all diagnostic criteria,

(per DSM-IV-TR)

 

Per 299.00 in DSM-IV-TR

Physician or ARNP associated with an

evidence of delay or abnormal functioning prior to age five (5) in

 

 

 

autism center, developmental center,

social, language, communication skills or symbolic or

 

 

 

or center of excellence, or a Board

imaginative play, and adaptive skills test showing substantial

 

 

 

Certified: Neurologist, Psychiatrist, or

limitations in adaptive functioning of more than two standard

 

 

 

Developmental and Behavioral

deviations below the mean.

 

 

 

Pediatrician

 

 

 

 

 

 

Autism Spectrum

 

Autism Spectrum Disorder

A Licensed Psychologist, a Licensed

Full evaluation per DSM-V meeting all diagnostic criteria,

Disorder

299.00

Physician or ARNP associated with an

evidence of delay or abnormal functioning prior to age five (5),

(per DSM-5)

 

Per DSM-5

autism center, developmental center,

adaptive skills test showing substantial limitations in adaptive

 

 

 

or center of excellence, or a Board

functioning of more than two standard deviations, and FSIQ of

 

 

 

Certified: Neurologist, Psychiatrist, or

one standard deviation or more below the mean.

 

 

 

Developmental and Behavioral

 

 

 

 

Pediatrician

 

 

 

 

 

 

Another Neurological

 

Neurological or chromosomal

Licensed Physician

Full Scale IQ score of more than 1.5 standard deviations below

or Other Condition

 

disorder known to cause

 

the mean and adaptive skills test showing substantial limitations

Similar to Intellectual

 

intellectual and adaptive skills

 

in adaptive functioning of more than two standard deviations

Disability

 

deficits

 

below the mean completed within the last 36 months.

 

 

 

 

 

Note: This form is a general guide only and DDA may require additional information or assessments. This documentation is the first step in determining eligibility. DDA eligibility is determined per WAC Chapter 388-823.

DSHS 10-301 (REV. 10/2021)

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