Maryland Department of Health

Developmental Disabilities Administration (DDA)

 

Self-Directed Services: Individual and Family Directed Goods and Services Request

This form is available for anyone who self-directs their DDA services in the State of Maryland. This form can be used to request Goods and Services as described in our guidance using cost savings from the person's budget


Only the participant's Coordinator of Community Services (CCS) may complete this form.


Please complete one form for each Individual and Family Directed Goods and Services request.


This form should not be used to request Recruitment, Advertising, or a Day to Day Administrator.


Please reach out to the DDA Regional Office if you have questions, concerns, or need technical assistance.


Please note, the Financial Management and Counseling Services provider cannot pay for any good or service that was purchased before approval.


*This form is effective November 21, 2024.

 

This is the LTSSID of the person who is self-directing their services

 
 
 
 
 

The request must be for an active and approved Self-Directed Services Person-Centered Plan.

 

Good / Service Request

 

From the list below, choose the category of Individual and Family Directed Goods and Services request

 
 

Describe why the Good / Service is needed.

 
 

This is the total amount for the Good / Service over the plan year

 

If the request was not included in the Self-Directed Services Budget Sheet, a Budget Modification must be completed.

 
 

Requirements for Individual and Family Directed Goods and Services Approval

 

Describe how the good / service helps the person meet a need or goal

 
 

Describe how the good / service helps the person maintain or increase independence

 
 

Describe how the good / service promotes those opportunities

 
 
 
 

Individual and Family Directed Goods and Services must decrease the need for Medicaid services, increase community integration, increase the participant’s safety in the home, or support the family in the continued provision of care to the participant.


Choose which requirement(s) this request meets. One must be selected, but more may be chosen

 

List all funding sources that were denied or not available related to this request

 
 

Describe how the good / service is cost effective for the person

 
 

Personal Funds Documentation

Individual and Family Directed Goods and Services requests may only be approved if the participant does not have personal funds to purchase the good/service.


Falsification of any portion of this form, including information related to personal funds, is considered Medicaid fraud.

 
 

Signatures and Uploads

By signing and submitting this Individual and Family Directed Goods and Services request, you are attesting that all the contents within the requests are accurate and complete.


Falsification of all or portions of this request is considered Medicaid fraud and subject to appropriate reporting.

 
Drop your files here
 

By typing my name below, I attest that the Participant/legal guardian/designated representative has made an informed decision.


Note: Completing this form before the participant/legal guardian/designated representative has made an informed choice is considered falsification of the document.

 

Send a copy of this form to the following people:

 
 
 

If the person self-directing uses email, include it here.