Regional Office Request for Assistance (RORA) Form

Thank you for utilizing the DDSD RORA system! DDSD created the RORA system to promote communication with external and internal partners and to provide a forum for raising concerns to DDSD. DDSD will review all submitted RORAs in a timely fashion then strategically employ assistance as necessary.

Please be aware: This is not an incident report form. Submission of this form does not constitute reporting as required by law. Abuse, Neglect, Exploitation and Deaths must be reported to our toll-free hotline: 1-800-654-3219.

Only questions containing an asterisk (*) are required

First Name of Individual

Indicate below the name of the individual you are requesting assistance for. If you are requesting assistance for multiple individuals, indicate the individual that brought this issue to your attention.

Last Name of Individual

Date of Birth

mm/dd/yyyy

Do you know the individual's Social Security #?

Managed Care Organization

Blue Cross Blue Shield

Molina Healthcare

Presbyterian Health Plan

United Healthcare Community Plan

MCO Care Coordinator

Indicate name of MCO care coordinator:

Key Diagnosis/Condition(s)

Provider Agencies

Services received

Submitted by:

Name of Submitter

Submitter's Title/Relationship to Individual

Phone number

Phone

Fax #

Phone

Consultant Agency

Describe Request

Provide description of the issue(s) you are requesting assistance with. Please include any relevant dates, identified barriers and list actions taken to resolve issue(s). Supporting documents may be attached below.

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