Form 06Mp001E PDF Details

The 06MP001E form serves as a vital gateway for individuals with developmental disabilities to access services provided through the Oklahoma Department of Human Services (OKDHS) Developmental Disabilities Services Division (DDSD). This comprehensive form lays the groundwork for applying to a range of supportive services but notably does not delve into the financial eligibility criteria for Medicaid-funded DDSD programs. It requests detailed information about the applicant, including but not limited to their personal identification, household composition, education, medical history, and any current services or benefits the individual is receiving. Moreover, the form requires documentation such as a Social Security card and a birth certificate, and information about the applicant's guardians or legal representatives. It inquires about the applicant's education, aiming to understand their current status and needs, and seeks to identify any medical or psychological assessments that could clarify the applicant's needs. The document also explores the types of developmental disability services the applicant wishes to access, underscoring the necessity of a legal guardian's or responsible party's consent to process the application. With embedded instructions on how to complete and where to return the form, the 06MP001E ensures that applicants and their families understand the steps towards receiving aid, while also setting expectations about the application's review timeline and the potential for waitlisting due to resource limitations.

QuestionAnswer
Form NameForm 06Mp001E
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesDDS-1, DDSD, OKDHS, oklahoma form 06mp001e dated 9 22 15

Form Preview Example

*06MP001E-001*

Request for Developmental Disabilities Services

Date

County

OKDHS case number

This form is used to apply for services to persons with developmental disabilities through OKDHS Developmental Disabilities Services Division (DDSD). This application does not address financial eligibility requirements for Medicaid funded DDSD services.

Section 1. Applicant

Applicant legal last name

 

First

 

Middle

 

Area code

 

Home phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

City

 

 

 

 

State

 

 

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Also known as

 

 

 

 

Date of birth

 

Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

 

Area code

 

Home phone

Social Security number, attach copy of card

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

United States citizen

 

 

 

 

Resident alien

 

 

 

 

 

Yes

No

 

 

 

 

Yes

No

 

 

 

 

 

Marital status:

 

 

 

 

Language spoken or understood by applicant

Married

 

Single

Divorced

 

 

 

 

 

 

 

 

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant employed

 

 

 

 

If yes, employer:

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Completed by state employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who has legal custody?

 

 

 

 

County of adjudication

Adjudication date

 

 

 

 

 

 

 

 

 

 

Primary worker

Area code

Work phone

Supervisor

 

Area code

 

Work phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If OKDHS or Office of Juvenile Affairs (OJA) has legal custody, attach copy of order.

Type:

Temporary

Permanent

Form 06MP001E (DDS-1) revised 08-12-2010 may continue on next page, page 1 of 6

Section 2. Parents/guardian

Father

 

Area code

Home phone

Area code

Work phone

 

 

 

 

 

 

 

 

 

Street address

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

Mother

 

Area code

Home phone

 

Area code

Work phone

 

 

 

 

 

 

 

 

Street address

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

Legal guardian

 

Area code

Home phone

Area code

Work phone

 

 

 

 

 

 

 

 

Street address

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

Primary correspondent, if different

 

 

 

 

 

Relationship

 

 

 

 

 

 

 

Street address, if different

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

Secondary correspondent

 

 

 

 

 

Relationship

 

 

 

 

 

 

Street address

 

City

 

State

Zip

 

 

 

 

 

 

 

 

 

 

Section 3. Household members

 

 

Date of

 

Health

Name

Relationship

birth

Occupation

status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4. Medical

Attach copy of applicant's birth certificate.

Form 06MP001E (DDS-1) revised 08-12-2010 may continue on next page, page 2 of 6

Hospital or facility where applicant was born

Street address

City

State

Zip

1. Briefly describe any significant medical problems/disabilities experienced by applicant.

2.

Who is applicant's current primary care physician?

 

3.

Does applicant take any routine medication?

Yes

 

If yes, list medication, dosage, and reason for medication.

 

4. Has applicant been diagnosed with mental retardation, autism,

 

or mental illness?

Yes

No

No

If yes, list diagnosis

When

By whom

5. Has applicant had a psychological evaluation?

Yes

Attach copy, if available.

 

No

If yes, when

Where

By whom

I.Q.

Mental age

Describe any behavioral problems:

Section 5. Education

 

 

 

 

Is applicant currently attending school?

Yes

No

 

 

 

 

 

If yes, where

Special class

Regular class

Grade

 

 

 

 

 

 

Copy of applicant's current individualized education plan (IEP) available? Yes If yes, attach copy.

No

Form 06MP001E (DDS-1) revised 08-12-2010 may continue on next page, page 3 of 6

If out of school, where did applicant attend school?

Briefly describe applicant's adjustment to school regarding peer interaction and relationships with teachers.

Section 6. Additional information

Services currently receiving from the school, community, and other agencies:

Check all that apply. Currently receiving: Supplemental Security Income (SSI)

Social Security Administration (SSA) payment

Medicaid

Medicare

Requested DDSD services:

• Home and Community-Based Services (HCBS)

• eligibility for state-funded group home/assisted living without waiver supports

• state-funded workshop/community integrated employment

What kind of help do you need?

l authorize OKDHS to make this application available for evaluation services to agencies designated by OKDHS. l further agree to comply with all applicable laws, rules, and regulations, and understand that services and benefits for persons with developmental disabilities are equally available to all persons without regard to race, color, religion, or national origin. I understand that I may cancel or withdraw this application for services by submitting written request to the appropriate DDSD area office.

The information in this application is correct to the best of my knowledge:

Legally responsible party/applicant signature

Date

If applicant is age 18 or older and does not have a legal guardian:

Person assisting applicant signature

Date

OKDHS action regarding this application must occur within 180 days from the date of receipt by OKDHS of the completed application. When state DDSD resources are

Form 06MP001E (DDS-1) revised 08-12-2010 may continue on next page, page 4 of 6

unavailable to serve new applicants in the HCBS program, they are placed on a statewide waiting list.

Return to DDSD office in the area where applicant resides.

DDSD Area I Office

729 Overland Trail

Enid, OK 73703

Toll free: 1-800-522-1064; and

DDSD Area I Office

2401 NW 23rd Street, Suite 28 Oklahoma City, OK 73107-2442

Toll free: 1-800-522-1064

Covers: Alfalfa, Beaver, Blaine, Canadian, Cimarron, Custer, Dewey, Ellis, Garfield, Grant, Harper, Kay, Kingfisher, Lincoln, Logan, Major, Noble, Oklahoma, Payne, Roger Mills, Texas, Woods, and Woodward

DDSD Area II Office 1427 East 8th Tulsa, OK 74120

Toll free: 1-800-522-1075

Covers: Adair, Cherokee, Craig, Creek,

Delaware, Mayes, McIntosh, Muskogee,

Nowata, Okfuskee, Okmulgee, Osage,

Ottawa, Pawnee, Rogers, Sequoyah,

Tulsa, Wagoner, and Washington

DDSD Area III Office

301 South Indian Meridian Road Pauls Valley, OK 73075

Toll free: 1-800-522-1086

Covers: Atoka, Beckham, Bryan,

Caddo, Carter, Choctaw, Cleveland,

Coal, Comanche, Cotton, Garvin,

Grady, Greer, Harmon, Haskell,

Hughes, Jackson, Jefferson, Johnston,

Kiowa, Latimer, LeFlore, Love,

Marshall, McClain, McCurtain, Murray,

Pittsburg, Pontotoc, Pottawatomie,

Pushmataha, Seminole, Stephens,

Tillman, and Washita

Form 06MP001E (DDS-1) revised 08-12-2010 may continue on next page, page 5 of 6

How to Edit Form 06Mp001E Online for Free

Through the online tool for PDF editing by FormsPal, you're able to complete or modify DDS-1 here and now. We are devoted to making sure you have the perfect experience with our tool by constantly adding new features and enhancements. With these improvements, working with our editor gets better than ever before! Getting underway is simple! All that you should do is stick to the following easy steps directly below:

Step 1: Just press the "Get Form Button" at the top of this site to access our form editor. There you will find everything that is required to fill out your document.

Step 2: As you access the PDF editor, you will get the document ready to be filled in. Apart from filling in various blanks, you may as well do some other actions with the PDF, specifically putting on custom text, editing the initial textual content, adding images, affixing your signature to the PDF, and more.

This PDF form will need specific information to be filled in, thus ensure you take whatever time to fill in precisely what is requested:

1. It is critical to complete the DDS-1 properly, therefore be attentive while filling out the areas containing all these blank fields:

Filling in section 1 in HCBS

2. Soon after filling in this step, go on to the subsequent part and complete all required details in these blanks - United States citizen Yes Marital, Single, Divorced, If yes employer, Completed by state employee, Who has legal custody, County of adjudication, Primary worker Area code Work, If OKDHS or Office of Juvenile, Permanent, Temporary, and Form MPE DDS revised may continue.

Temporary, If OKDHS or Office of Juvenile, and County of adjudication inside HCBS

3. The following portion is all about Father, Area code Home phone Area code, Street address, City, State Zip, Mother, Area code Home phone Area code, Street address, City, State Zip, Legal guardian, Area code Home phone Area code, Street address, City, and State Zip - fill in each one of these fields.

Filling out part 3 of HCBS

4. The fourth paragraph arrives with all of the following blank fields to type in your details in: Street address, City, State Zip, Section Household members, Name, Relationship, Date of, birth, Occupation, and Health status.

Best ways to fill in HCBS part 4

5. The document must be finalized by going through this section. Further you can find a comprehensive list of form fields that require correct details to allow your document submission to be complete: Section Medical, Attach copy of applicants birth, and Form MPE DDS revised may continue.

Section Medical, Attach copy of applicants birth, and Form MPE DDS revised may continue in HCBS

Always be really attentive while filling in Section Medical and Attach copy of applicants birth, as this is the part in which most users make mistakes.

Step 3: Before submitting this file, it's a good idea to ensure that blank fields have been filled in the correct way. As soon as you are satisfied with it, press “Done." Make a free trial subscription at FormsPal and gain immediate access to DDS-1 - download or edit in your personal cabinet. FormsPal guarantees your data privacy by using a protected method that never saves or shares any private data involved. Feel safe knowing your docs are kept confidential each time you work with our services!

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