I/DD Transfer Form

Client’s information
Last name First name Middle name/initial
                 
Prime number Birthdate Gender
                 
Current address City State Zip
                       
Phone number Primary language Marital status
                 

Guardian or primary contact (if applicable)

Relationship Court-appointed
Name
(e.g., parent, guardian) guardian?
            Yes No
Contact’s phone number Contact’s address
           

Transfer information
Date of transfer request Type of transfer
      Select one
Reason for transfer/other notes
     

Required documents to transfer eligibility

Sending CDDP
     
CDDP transfer contact Email Phone number
                 
Yes No
Authorization to release eligibility records
Initial intake/application form or confirmation of request for services
form
DD eligibility enrollment form (DHS 0337)
Eligibility statement, letters and supporting eligibility documents
Eligibility notices sent to the client

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 Progress notes from initial eligibility determination and
redetermination(s)
Legal documents (guardianship order, DHS commitment order, etc.)
Other:      
Other:      

Case management documents to transfer services

Enrollment plan or notes
{Select}
{Select}
{Select}
Sending case management entity
     
Contact person Email Phone number
                 

Yes No
Authorization to release records
Face sheet/demographics
Progress notes from last six months
Level of care (initial evaluation with annual review signatures)
Individual Support Plan (ISP) or Annual Plan
ISP or Annual Plan supporting documents (e.g., PCI, RI)
Functional needs assessment and any additional needs assessments
and/or support plans
Behavior support plan, protocols and/or safety plans
Plan of care printout
Fiscal intermediary documents
Employment-related documents
Other supplemental supporting documents (e.g., assistive technology)
Other:      
Other:      
Case manager’s notes
     

Page 2 of 2 SDS 0702 (7/2016)