Opwdd form 159 2026

1. Click ‘Get Form’ to open OPWDD Form 159 in the editor.
2. In the Registered Provider/Agency Area, enter the full name of the registered provider and agency, along with the complete street address, city, state, and zip code.
3. Fill in the Authorized Person’s Name, phone number, and email address. This person will be responsible for submitting CBC requests.
4. In the Applicant Information section, list all household members. Start with the applicant's name followed by any maiden names or aliases. Ensure all names are recorded accurately.
5. Indicate each person's relationship to the applicant in the first column. Fill in M or F for sex and complete dates of birth for everyone listed.
6. Provide addresses for the applicant over the last 28 years. Include complete details and attach supplemental pages if necessary.
7. Ensure all required signatures are completed in the Signature Area, including dates for each signature.

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