Skip Navigation
The Official Web Site of the State of South Carolina Show SC.gov Links

Forms by Category 

 

INDEX OF PDD WAIVER & STATE FUNDED PROGRAM FORMS

by

CATEGORY

 


     

Forms

 

 

     

 

 

     

General PDD Forms

     

 

 

 

PDD Form 1-A 

 

Acknowledgement of Rights and Responsibilities - PDD Waiver

 

PDD Form 1-B

 

Acknowledgement of Rights and Responsibilities - PDD State Funded Program

 

PDD Form 2

 

Freedom of Choice - PDD Waiver

 

PDD Form 3

 

Acknowledgement of Choice of Case Management

 

PDD Form 5

 

Notice of Slot Allotment - PDD Waiver

 

PDD Form 9

 

Request for ICF/ID Level of Care for the PDD Waiver

 

PDD Form 10

 

Notice of Slot Allotment - PDD State Funded Program

 

PDD Form 11

 

Authorization for Case Management Services - PDD Waiver

 

PDD Form 12

 

Authorization for EIBI Services - PDD Waiver

 

PDD Form 13

 

Authorization for EIBI Services - PDD State Funded Program

 

PDD Form 16-A

 

Notice of Termination of Service - PDD Waiver

 

PDD Form 16-B

 

Notice of Termination of Service - PDD State Funded Program

 

PDD Form 17-A

 

Notice of Disenrollment - PDD Waiver

 

PDD Form 17-B

 

Notice of Disenrollment - PDD State Funded Program

 

PDD Form 18

 

PDD State Funded Program Billing Form

 

PDD Form 20-A

 

Statement of Individual Declining PDD Waiver Services

 

PDD Form 20-B

 

Statement of Individual Declining PDD State Funded Services

 

PDD Form 21

 

EIBI Provider Application

 

PDD Form 22A-C

 

EIBI Provider Enrollment Packet

 

PDD Form 30

 

Request for PDD Slot Allocation Application

 

PDD Form 31-A

 

Reconsideration /Appeals Process - PDD Waiver

 

PDD Form 31-B

 

Reconsideration/Appeals Process - PDD State Funded Program

PDD Form 33

Authorization for Temporary EIBI Services - PDD State Funded Program

PDD Form 34

Notice of Disenrollment of Temporary Services - PDD State Funded Program

PDD Form 40

Consultant Recertification Application

PDD Form 41

Consultant Annual Renewal Application

PDD Form 42

Consumer Insurance Verification

PDD Form 43

Pre Assessment Information

PDD Form 44

Temporary EIBI State Funded Program Enrollment Agreement

 

 

 

 

 

Responsible Party Forms

 

  

 

 

PDD Form RP 1

 

Pre-Screening Assessment of Responsible Party - PDD Program

 

PDD Form RP 2

 

Checklist of Items Needed for PDD Program Responsible Party-Direction of Services

 

PDD Form RP 5

 

Responsible Party Information Sheet - PDD Program

 

PDD Form RP 8

 

Line Therapist Information Sheet - PDD Program

 

PDD Form RP 9

 

Electronic Funds Transfer and Payroll Tax Deduction Authorization

 

PDD Form RP 10

 

Employee Payment Agreement - PDD Responsible Party Directed Services

 

PDD Form RP 11

 

Line Therapist Responsibilities Agreement - PDD Program

 

PDD Form RP 12-A

 

Line Therapy Services Liability Statement - PDD Waiver

PDD Form RP 12-B

Line Therapy Services Liability Statement - PDD State Funded Program

 

PDD Form RP 15

 

Line Therapist Qualifications Checklist - PDD Program

PDD Form RP 15-A

PDD Tuberculin Skin Test Requirements

 

PDD Form RP 16

 

Responsible Party Line Therapy Daily Log - PDD Program

 

PDD Form RP 17

 

Authorization for Responsible Party Line Therapy -PDD Waiver

 

PDD Form RP 18

 

Authorization for Responsible Party Line Therapy - PDD State Funded Program

 

PDD Form RP 19

 

Responsible Party Line Therapist Invoice

 

Form SS-4

 

Application for Employer Identification Number

 

Form 8821

 

Tax Information Authorization

 

Form 2678

 

Employer/Payer Appointment of Agent

 

Form I-9

 

Employment Eligibility Verification

 

Form W-4

 

Employee’s Withholding Allowance Certificate

Form DSS 3072

Consent to Release Information

 

 

Intake and Referral Forms

 

 

 

 

 

PDD Form IR 1-A

 

Information and Referral Application Packet-Process Explanation

 

PDD Form IR 1-B

 

Information and Referral Application Packet-Records Request Letter

 

PDD Form IR 1-C

 

Information and Referral Application Packet-Authorization for Release of Information

 

PDD Form IR 1-D

 

Information and Referral Application Packet-

Acknowledgement of Case Management Choice

 

PDD Form IR 2

 

Recommendation for Evaluation

PDD Form IR 3

Notice of Denial of Services (Appeal Information Attached)

 

 

 

 

 

Consumer Assessment Forms

 

 

 

 

 

LOCS Form 1 

 

Level of Care Staffing Report

 

LOCD Form 2

 

Level of Care Determination for ICF/ID

 

LOCC Letter 

 

Level of Care Certification Letter

 

 

 

 

 

Information Documents

 

 

 

 

Info-Sheet 1

 

Pervasive Developmental Disorder Waiver Information Sheet

 

Info-Sheet 2

 

Pervasive Developmental Disorder Program Fact Sheet

 

Info-Sheet 8

 

Responsible Party Directed Care Enrollment Information