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

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.

Select
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xxx-xx-xxxx

Waiver Type*
Managed Care Organization

Indicate name of MCO care coordinator:

Regional Office*
County

Name of Submitter

Phone
Phone
Phone
Phone
Phone
Phone
Are you requesting short-term Therapy Consultation Services?*

(Safety net)

Therapy Services needed*

Choose one

Requested Therapy on Budget?*

Has the requested therapy service been on the individual's ISP budget within the past year?

Please Note

The following 5 conditions must be met prior to submission of short-term Safety Net Services:

Condition 1: IDT involvement*

Has the IDT met to discuss this need and followed the Procedure for accessing Safety Net Service?

Condition 2: Therapy Service is essential*

The IDT determined that therapy services being requested are essential to the individual’s health, safety, daily functioning, or achievement of ISP Visions and Outcomes and the therapy services being requested cannot be provided by or is not appropriate to refer to other Insurance Providers (Use of Doctor’s order and insurance card).

Condition 3: IDT discussed other alternatives*

The IDT has discussed and determined that therapy services requested cannot be provided by another therapy discipline, other IDT members, and/or integrating strategies into the ISP.

Condition 4: Guardian involvement*

Has this request has been discussed with the guardian?

Condition 5: Unavailability in county verified*

Did you verify that there is no therapist of the discipline requested currently listed on the DDSD Secondary Freedom of Choice (SFC) website for this county?

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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