Service Providers Information

Rates for Work Activity Program (service code 954) and Supported Employment (service codes 950 and 952) can be found by regional center on the rates page:

DS 1961 SEP – SEP/Individual Habilitation Services Plan This form is the standardized service plan Supported Employment Program (SEP). Providers use to implement the consumer’s vocational goals of the Individual Program Plan (IPP).

Users: SEP service providers.

DS 1972 SEP IP – SEP/Supported Employment Individual Placement Consumer Monthly Report Outcome data for consumers provided Supported Employment Program- Individual Placement services is documented on this form. Users: SEP Services Providers; Regional Center can preload consumer names and identification numbers.

DS 1962 – Request For New SEP Groups A Supported Employment Program-Group Placement (SEP-GP) approval request is submitted by service providers to DDS to obtain approval of new SEP Groups. Users: SEP-GP service providers.

DS 1963 – Request For Approval Of SEP Group Changes This form is submitted by service providers to request changes in a specific approved supported employment program group. Users: SEP-GP service providers.

DS 1964 – Supported Employment Group Billing and Attendance Form This form must be completed as an excel file, password protected and submitted to regional centers, DOR and DDS monthly. After downloading the file, enter the vendor information at the top of the form and consumer and job coach information up to the “Funded By” column. Save a copy of this file as a “master”. Should any problem arise with the form, the “master” is available to start over.

DS 1961 WAP – WAP/Individual Habilitation Services Plan This form is the standardized service plan Work Activity Program (WAP). Providers use to implement the consumer’s vocational goals of the Individual Program Plan (IPP). Users: WAP service providers.

DS 1971 WAP – WAP/Work Activity Program Consumer Monthly Report Outcome data for consumers provided Work Activity Program services is documented on this form. Users: WAP Services Providers; Regional Center can preload consumer names and identification numbers.

DS 1968 – Vocational Rehabilitation Referral This form is used to refer consumers to the Department of Rehabilitation for Vocational Rehabilitation Services. Users: Regional Center Service Coordinators.

DS 1969 – Vocational Services Exit Report This form is completed when a consumer exits a habilitation services program. Users: Regional Center Service Coordinators and Habilitation Services Providers.

The forms below are for work services (formerly Habilitation) providers to report all revenue and expenses biennially to the Department.

The Excel forms can be downloaded and complete using Microsoft Excel spreadsheet program. For further information, please read the instructions accompanying each form. DS 1950 – Habilitation Services Cost Statement Forms

DS 1966 – Request for Rate Adjustment — Occupancy Change

DS 1967 – Request for Rate Adjustment — Staffing Change


Share  

Last modified: October 18, 2024