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.

 
 
 
mm/dd/yyyy
 
 
 
 

Indicate name of MCO care coordinator:

 
 
 
 
 
 
 
 
 

Name of Submitter

 
 
 
Phone
 
Phone
 
 
 

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.

 
 
Drop your files here