​​​​​​​​Waivers & Policies > Forms​​​​​​​​​​​​​​

Thi​​​s page is the main location for forms and worksheets related to DDA services, supports, and programs. The Table of Contents below can help you quickly navigate to the topic you are interested in.

Fiscal Fo​​​​​r​​​​ms

​​​​Financial Incident Report Form

The DDA maintains a financial incident reporting system for DDA providers in accordance with a recommendation by the Task Force on the Quality of Services for Individuals with Developmental Disabilities.

The financial incident report form must be completed biannually by DDA providers. ALL DDA providers are required to submit a signed and completed copy of the form twice a year (October 31 and April 30 annually).  The form due on October 31 covers April through September and the form due on April 30 covers October through March.

Forms should be returned to dda.reconciliations@maryland.gov with the subject header “FINANCIAL INCIDENT REPORT FORM.” These forms are due by April 30 and October 31 each year.

• Financial Incident Rep​ort Form April-September, Due October 31
• Financial Incident Report Form October-March, Due April 30
  

In addition, DDA expects all agencies licensed by or under contract with DDA to report bankruptcy filings to the Chief Financial Officer of DDA and the Provider Relations office within 24 hours of the filing.​

​Contributions ​to Care and Room and Board

Contributions to Care (CTC) Invoices:

• Client Fee Reimbursement Invoice Form,  July 2, 2018
  
• Client Fees Reimbursement Instructions, May 1, 2015
  
• CTC Invoicing Changes Memo, May 5, 2015​​

Other CTC Documentation:

• Eligibility Determination Division (EDD) DDA Contact Information (Oct. 23, 2015)
• EDD DDA Change Unit CTC Procedures (Oct. 23, 2015)
• EDD DDA Change Report Form (Oct. 23, 2015)
• EDD Change in CTC Letter (Oct. 23, 2015)
• Memo - CTC Discrepancy (Aug. 21, 2015)
• EDD DDA Request for Non-Covered Services Form (Aug. 6, 2014)
• January 31 2014 CTC Changes (Jan. 31, 2014)​
  
  

Cost Det​ail Tool

• ​Cost Detail Tool FY24 - FY25​​

Cost Reports a​nd ​​Wage Survey​

Webinar & PowerPoint

• Webinar
• DDA Cost Reports Training Webinar, Nov. 2, 2017 (PowerPoint)
  

FY2024 Cost Report

• ​DDA FY 2024 Cost Report Instructions 11-14-2024
  
• Cost Report Template FY24 11-14-2024​​​
• Independent Auditor's Report - FY24 Cost Report 11-14-2024​
  

FY2023 Cost Report

• ​DDA FY 2023 Cost Report Instructions 10-03-2023
• Cost Report Template FY 23 10-4-2023​​​
• Independent Auditor's Report - FY 23 Cost Report 10-03-202​3

FY2022 Cost Report

• ​DDA FY 2022 Cost Report Instructions 11-15-2022
• Cost Report Template FY 22 11-15-2022​​​​
• Independent Auditor's Report -FY 22 Cost Report 11-15-22​​

FY 2021 Cost Report

• ​DDA FY 2021 Cost Report Instructions 11-5-2021
• Cost Report Template FY 21 11-5-2021
• Independent Auditor's Report - FY 21 Cost Report 11-5-2021​

FY 2020 Cost Report

• ​DDA FY 2020 Cost Report Instructions 10-28-2020
• Cost Report Template FY 20 12-1-2020​
• Independent Auditor's Report - FY 20 Cost Report​​

Federal Billing Forms

• ​LTSS Billing Claims Su​​mmary Forms - Exceptions​​​
• Personal Support 2:1 Billing Form​
• Personal Support 2_1 Summary Form 040122
• Personal Support 2_1 Summary Form 070122v2
• Sample CMS 1500 Form, Sept. 16, 2015 
• Sample CMS 1500 Form, Feb 28, 2015 
• Maryland Medicaid CMS-1500 Paper Billing Instructions, April 1, 2015 
• ​​HIPAA Electronic Claim Submission
• Eligibility Verification System User Guide, March 31, 2013
• Trading Partner Agreement, March 21, 2012 
• Submitter Identification Form, March 21, 2012​​
  
  

Provider ​Agreement

• Rate Based Provider Agreement
• FSS, IFC and ISS Provider Agreement
  

DDA Procurement ​​Exemption

• DDA 432 Summary Exempt Format
• DDA 432 Summary Non-Exempt Format
• DDA 432 A-H Non-Exempt
• DDA 432 A-H Exempt
• DDA 437 Form
• DDA 438 Form
• DDA 440 Form
• DDA 440A-1 Form
• DHMH 433 Form
• DHMH 434 Form
• Roster Form