Transcription of If you need help with this application, call ... - Maryland
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If you need help with this application, call ... - Maryland
Developmental Disabilities Administration April 5, 2018 Page 1 Maryland Department of Health DEVELOPMENTAL DISABILITIES ADMINISTRATION APPLICATION FOR ELIGIBILITYTo determine eligibility for the Developmental Disabilities Administration (DDA) services, whether state or medicaid funded, you must complete this form. Low Intensity Support Services (LISS) do not require an you need help with this application, call Toll Free 1-877-4MD-DHMH * TTY for Disabled - Maryland Relay service 1-800-735-2258 LAST Name FIRST Name MIDDLE Name Date of Birth (MM/DD/YYYY): Permanent Mailing Address: Street AddressApt#CityStateZip CodeCounty of ResidenceAre you a resident of Maryland ? Telephone:Email:Day Cell Evening/OtherHave you ever applied for Medical Assistance in Maryland ?
Chemical dependency (Includes alcoholism) Cystic fibrosis. Deafness/Severe hearing impairment Epilepsy/Seizure disorder. Head injury Intellectual Disability. Multiple sclerosis Orthopedic impairment. Speech/Language impairment Spina bifida. ... DDA needs information from professionals and
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