Below is a list of the current forms used by the Office of Developmental Programs (ODP).

  • Some forms contain instructions for completion.
  • Some forms are in pdf format.  If you have difficulty opening these files, you may need a newer version of Adobe Reader.  Get Adobe Reader.
  • Some forms are labeled User Friendly (UF).
    • Information entered directly on UF forms will not be saved.  Remember to print the completed form, then scan and email or fax a hard copy to the intended receiver.
    • Be sure to print UF forms prior to closing the document, otherwise all the information entered will be lost.
Form Number Form Title
              UF Approved Program Capacity Change Request Form
DP 250 Certification of Need for ICF/MR Level of Care (pdf)
DP 250-S La certificación de la Necesidad para ICF/MR Nivel de Forma de Cuidado (pdf)
DP 251 Annual Recertification of Need for ICF/MR Level of Care (pdf)
DP 251-S Recertification anual de la Necesidad para ICF/MR Nivel de Forma de Cuidado (pdf)
DP 457  Home and Community Based or ICF/MR Application and Service Delivery Preference Form (pdf)
DP 457-S  En casa y Comunidad-Basó o ICF/MR Aplicación y Forma de Preferencia de Entrega de Servicio (pdf)
DP 458  Fair Hearing Request Form Home & Community Based Waiver Services for Individuals with MR (pdf)
DP 458-S  Justo Oyendo Forma de Petición  (pdf)
DP 1006 AWC Authorized Surrogate DesignationForm (pdf)
DP 1006-S Formulario Para Designar Subrogado Autorizado Form (pdf)
DP 1007 AWC Managing Employer/Surrogate Agreement Form (pdf)
DP 1008 AWC Documentation of Support Service Worker Qualification Form (pdf)
DP 1009 AWC Emergency Back-Up “Qualified” Support Service Worker or Natural Support Designation Form (pdf)
DP 1010 AWC Monthly Progress Notes (pdf)
DP 1017 Service Provider Choice for Autism Services Form (pdf)
DP 1017-S Atienda a Elección de Proveedor para la Forma de Servicios de Autismo
DP 1018 Service Preference for Autism Services Form (pdf)
DP 1018-S Atienda a Preferencia para la Forma de Servicios de Autismo (pdf)
DP 1019 Supports Coordinator Choice Form (pdf)
DP 1019-S Fomulario de Seleccion del Coordinador de Apoyos (pdf)
DP 1022 UF Waiver Service Request Form  (User Friendly)
DP 1022- S UF Oficina de Programas para el Desarrollo Formulario de Solicitud de Servicios de Exención (pdf)
DP 1023 Request for Exception to Established Service Limits (pdf)
DP 1023-S UF Solicitude de Excepción a Límites Establecidos de Servicios o Cantidad Máxima de Unidades de Servicio (pdf)
DP 1024 UF Provider Vacancy Management Notification Form (User Friendly) (pdf)
DP 1025 Unanticipated Emergency Funding Request and Approval (pdf)
DP 1030 Exception Request to Exclude Room and Board Charges Form (pdf)
DP 1031 Supplemental Hab & Additional Individualized Staffing Prior Authorization Instructions Form (pdf)
DP 1032  ISP Signature Form (pdf)
DP 1032-S UF Formulario de Firma del Plan de Asistencia Individual (pdf)
DP 1033 Unanticipated Emergency Screening Tool 11 (pdf)
DP 1035 SH/AIS ISP Checklist Form (pdf)
DP 1037 Request for the Provision of Emergency Respite Services
DP 1050 UF ISP Review Checklist (pdf)
DP 1051 Room and Board Contract Under 55 Pa. Code Chapter 51 – DP 1051 (pdf)
DP 1051 Contrato de alojamiento y comida de conformidad con el Capítulo 51 del Título 55 del Código de Pennsylvania
MA 51 MA 51 Medical Evaluation (pdf)
MA 97 MA 97 Outpatient Service Authorization Request Form and Instructions (pdf)
  HCSIS Verification Form and Instructions
PA 1768  PA 1768 HSBS Eligibility/Ineligibility/Change Form (pdf)
RTRAH Annual Right to Report Abuse Notification Form (pdf)