Provider Forms

ALL SERVICE PROVIDERS:

1. Become a Provider – Contact the appropriate Resource Coordinator to apply to become an SDRC Service Provider.

2. Vendor Disclosure Statement (DS1891) – Review the Department of Developmental Services information about the DS1891 form requirement.

NURSING LEVEL RESPITE PROVIDERS:

1. Nursing Level Respite Services Report

RESIDENTIAL SERVICE PROVIDERS:

1. Board & Care Payment Ledger 

2. Centrally Stored Medication & Destruction Record

3. Checklist for Consumer Documentation

4. Client/Resident Personal Property & Valuables

5. Directions for Consumer Health Record

6. Face Sheet

7. Handling of Consumer Funds Held in Trust 

8. Height & Weight Record 

9. Looking at Service Quality – Providers handbook required to be kept in all vendored Community Care licensed homes

10. Medical Visit Record

11. Medication Administration Instructions 

12. Medication Administration Record

13. Ongoing Consumer Notes 

14. Physician’s Report for Community Care Facilities

15. Provider of Care Claim Form

16. Record of Client’s/Resident’s Safeguard Cash Resources

17. Rights of Individuals with Developmental Disabilities

18. Seizure Record

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