Service Provider Forms
All Service Providers
- Community Services Contact Page
- Frequently asked questions regarding the approval process involved in becoming a service provider.
- Vendor Disclosure Statement (DS1891) – Review the Department of Developmental Services information about the DS1891 form requirement. FORM.
- Breach Incident Report Form (DS5340B)
- Vendor breaches also need to be reported to the U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) online HERE.
- Certification of Alternative Nonresidential Services – Providers shall complete and submit this form to the Regional Center to certify the provision of alternative nonresidential services before submitting claims for reimbursement. FORM.
- Board & Care Payment Ledger
- Centrally Stored Medication & Destruction Record
- Checklist for Consumer Documentation
- Client/Resident Personal Property & Valuables
- Directions for Consumer Health Record
- Face Sheet
- Handling of Consumer Funds Held in Trust
- Height & Weight Record
- Looking at Service Quality – The provider’s handbook is required to be kept in all vendored Community Care licensed homes.
- Medical Visit Record
- Medication Administration Instructions
- Medication Administration Record
- Ongoing Consumer Notes
- Physician’s Report for Community Care Facilities
- Provider of Care Claim Form
- Record of Client’s/Resident’s Safeguard Cash Resources
- Rights of Individuals with Developmental Disabilities
- Seizure Record
- DS 1890 – Vendor Application (English)
- DS 1890 – Vendor Application (Spanish)
- DS 1891 – Applicant/Vendor Disclosure Statement
- Conflict of Interest Form Nursing Level Respite Services Report
- eBilling Enrollment Form Nursing Level Respite Services Report
- HCBS Provider Agreement
- SDRC SPP Agreement Form
- W9 Form
