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Waivers & Policies > Forms
This page is the main location for forms and worksheets related to DDA services, supports, and programs. The Table of Contents below can help you quickly navigate to the topic you are interested in.
Financial Incident Report FormThe DDA maintains a financial incident reporting system for DDA providers in accordance with a recommendation by the Task Force on the Quality of Services for Individuals with Developmental Disabilities.The financial incident report form must be completed biannually by DDA providers. ALL DDA providers are required to submit a signed and completed copy of the form twice a year (October 31 and April 30 annually). The form due on October 31 covers April through September and the form due on April 30 covers October through March.Forms should be returned to dda.reconciliations@maryland.gov with the subject header “FINANCIAL INCIDENT REPORT FORM.” These forms are due by April 30 and October 31 each year. Financial Incident Report Form April-September, Due October 31 Financial Incident Report Form October-March, Due April 30In addition, DDA expects all agencies licensed by or under contract with DDA to report bankruptcy filings to the Chief Financial Officer of DDA and the Provider Relations office within 24 hours of the filing. Contributions to Care and Room and BoardContributions to Care (CTC) Invoices: Client Fee Reimbursement Invoice Form, July 2, 2018 Client Fees Reimbursement Instructions, May 1, 2015 CTC Invoicing Changes Memo, May 5, 2015Other CTC Documentation: Eligibility Determination Division (EDD) DDA Contact Information (Oct. 23, 2015) EDD DDA Change Unit CTC Procedures (Oct. 23, 2015) EDD DDA Change Report Form (Oct. 23, 2015) EDD Change in CTC Letter (Oct. 23, 2015) Memo - CTC Discrepancy (Aug. 21, 2015) EDD DDA Request for Non-Covered Services Form (Aug. 6, 2014) January 31 2014 CTC Changes (Jan. 31, 2014)Cost Detail ToolCost Detail Tool FY24 - FY25Cost Reports and Wage Survey
The DDA maintains a financial incident reporting system for DDA providers in accordance with a recommendation by the Task Force on the Quality of Services for Individuals with Developmental Disabilities.The financial incident report form must be completed biannually by DDA providers. ALL DDA providers are required to submit a signed and completed copy of the form twice a year (October 31 and April 30 annually). The form due on October 31 covers April through September and the form due on April 30 covers October through March.Forms should be returned to dda.reconciliations@maryland.gov with the subject header “FINANCIAL INCIDENT REPORT FORM.” These forms are due by April 30 and October 31 each year.
In addition, DDA expects all agencies licensed by or under contract with DDA to report bankruptcy filings to the Chief Financial Officer of DDA and the Provider Relations office within 24 hours of the filing.
Webinar & PowerPoint
Webinar DDA Cost Reports Training Webinar, Nov. 2, 2017 (PowerPoint)
FY2023 Cost Report
DDA FY 2023 Cost Report Instructions 10-03-2023 Cost Report Template FY 23 10-4-2023 Independent Auditor's Report - FY 23 Cost Report 10-03-2023
FY2022 Cost Report
DDA FY 2022 Cost Report Instructions 11-15-2022 Cost Report Template FY 22 11-15-2022 Independent Auditor's Report -FY 22 Cost Report 11-15-22
FY 2021 Cost Report
DDA FY 2021 Cost Report Instructions 11-5-2021 Cost Report Template FY 21 11-5-2021 Independent Auditor's Report - FY 21 Cost Report 11-5-2021
FY 2020 Cost Report
DDA FY 2020 Cost Report Instructions 10-28-2020 Cost Report Template FY 20 12-1-2020 Independent Auditor's Report - FY 20 Cost Report
Federal Billing Forms
LTSS Billing Claims Summary Forms - Exceptions Personal Support 2:1 Billing Form Personal Support 2_1 Summary Form 040122 Personal Support 2_1 Summary Form 070122v2 Sample CMS 1500 Form, Sept. 16, 2015 Sample CMS 1500 Form, Feb 28, 2015 Maryland Medicaid CMS-1500 Paper Billing Instructions, April 1, 2015 HIPAA Electronic Claim Submission Eligibility Verification System User Guide, March 31, 2013 Trading Partner Agreement, March 21, 2012 Submitter Identification Form, March 21, 2012
Misc. Forms and Documents for Providers Excise Tax Exemption Request Cover Sheet Certification Regarding Environment Tobacco Smoke Vendor Electronic Fund Transfer U. S Department Of Health And Human Services Certification Regarding Lobbying Certification Regarding Debarment, Suspension, and other Responsibility Matters Individual Indicator Rating Scale OHCDS application Provider Agreement and Procurement Exemption Forms
Provider Agreement Rate Based Provider Agreement FSS, IFC and ISS Provider Agreement
DDA Procurement Exemption DDA 432 Summary Exempt Format DDA 432 Summary Non-Exempt Format DDA 432 A-H Non-Exempt DDA 432 A-H Exempt DDA 437 Form DDA 438 Form DDA 440 Form DDA 440A-1 Form DHMH 433 Form DHMH 434 Form Roster Form
Other Fiscal Forms LTSS State-Funded InvoiceCCS Mailing OTP Invoice ServiceFundingPlan-Updated, Aug. 18, 2016 Invoice for FY2019 Weather Related Closure Losses 3-5-2020 DDA Provider Electronic Funds Transfer (EFT) Payment Instructions State of Maryland ACH/Direct Deposit Authorization for Vendor Payments
Supports and Services Planning Tool, Oct. 10, 2018
