March 20, 2023
The purpose of this correspondence is to provide regional centers with the Department of Developmental Services (Department) approved standardized vendorization packet for Self- Directed Supports (Service Code 099), as described in the Department’s December 2, 2022 guidance. Regional centers shall require only the documents provided in the enclosed packet for all potential vendors interested in providing Self-Directed Supports. Any deviation from the use of this packet requires advance approval from the Department. The packet includes the following documents:
- Vendor Packet Checklist
- General Self-Directed Supports Qualifications and Agreement Form
- Financial Management Services Self-Directed Supports Qualifications and Agreement Form
- DS1890 Vendor Application with sample form and FAQs
- DS1891 Applicant/Vendor Disclosure Statement with sample form
- Conflict of Interest Form with FAQs
- Business Associate Agreement/HIPAA Form with FAQs
- Home and Community-Based Services Provider Agreement Form with sample form
- W-9 Request for Taxpayer Identification Number and Certification
Information about Self-Directed Supports can be found in the Department’s July 28, 2022 guidance.
If Self-Determination Program participants, family members, or prospective vendors have questions regarding this correspondence, they should contact their regional center.
Questions from regional centers should be directed to [email protected].
Sincerely,
Original Signed by:
VICKI L. SMITH, Ph.D.
Deputy Director
Policy and Program Development Division
This DDS directive may be available in other languages. Here is a link to the DDS website.
