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Forms, Checklists and Regulations for Program Plans

This page is designed for providers who are familiar with the Program Plan process. If you are new to this process, please visit the Program Plan Information and Development web page.

Forms:

• DS 1851 - Specialized Procedures Request Cover Sheet (PDF)
• DS 1852 - Health Facilities Program Application Form (complete both pages - PDF)
• DS 1853 - Training Program for ICF/DD-N Attendant(PDF)
• DS 5860 - Payee Data Record-ICF DD SPA Program (To replace STD. 204) (PDF)
• ICF DD SPA Acknowledgement and Authorization Form (PDF)

Checklists:

• ICF/DD-H Program Plan | ICF/DD-H Medication Training Program Plan (MS Word)
• ICF/DD-N Program Plan | ICF/DD-N Medication Training Program Plan (MS Word)

Regulations:

• State Operation Manuals, Appendix J (Code of Federal Regulations, Centers for Medicare and Medicaid Services - PDF)
• California Code of Regulations
• ICF/DD-N Draft and Amended Regulations (Title 22, Department of Health Services - PDF)

When your Program Plan is completed, submit the following to:

1. Program Plan packet and attachments
2. Consultants qualifying documents
3. Completed checklists

The appropriate staff will review your plan for clarity and content and will contact you if changes to your Program Plan are required.

The Nurse Consultant will review and approve the Medication Training Plans, Attendant Training, and Specialized Procedures.

If you have any questions, please contact the Health Facilities Program Section at (916) 654-1965, or send an e-mail to ddshfps@dds.ca.gov.