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Click ‘Get Form’ to open the confirmation of diagnosis form in our editor.
Begin by filling out the 'Consumer Information' section. Enter the last name, first name, city, street address, state (IN), date of birth, initial, county of residence, ZIP code, sex, last four digits of Social Security number, and telephone number.
Proceed to the 'DD Diagnosis' section. Here, provide the primary diagnosis and its date. If applicable, include any secondary and tertiary diagnoses along with their respective dates.
In the 'Signature of Physician' field, ensure that the physician signs and dates the form. Include their telephone number and address details as required.
Finally, review all entered information for accuracy before saving or printing the completed form for submission.

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Versions	Form popularity	Fillable & printable
2023	3.8 Satisfied (48 Votes)
2015	4.4 Satisfied (47 Votes)
2011	4.7 Satisfied (61 Votes)

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What is Indiana DDRS?

Bureau of Developmental Disabilities Services (DDRS), Indiana Family Social Services Administration. 402 W. Washington St., #W451,, P.O. Box 7083, MS26. Indianapolis, IN 46207-7083 (317) 2321240 bddshelp@fssa.in.gov .

How do I get a BDDS waiver in Indiana?

How do I apply? You or your guardian may apply for the Family Support Waiver by contacting your local Bureau of Developmental Disabilities Services office for an application packet. Applications can also be printed at .in.gov/fssa/ddrs/3349.htm.

What does Indiana Medicaid waiver cover?

Authorized waiver services may include: Adult Day Service. Adult Family Care. Assisted Living. Attendant Care. Self-Directed Attendant Care. Case Management. Community Transition. Environmental Modifications.

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