OPWDD Form 159 (6 12 2024)-2026

1. Click ‘Get Form’ to open the OPWDD Form 159 in our editor.
2. Begin by entering the Registered Provider Name, ensuring you use the full name without abbreviations. Fill in the complete street address, including city, state, and zip code.
3. In the Registered Provider Information section, input the Authorized Person’s Name, phone number, and email address. This person will be responsible for submitting CBC requests.
4. Move to the Applicant Information section. List all household members, including adults and children. Ensure names are recorded with last names first and include any maiden or alias names.
5. Complete the Address Area by providing addresses for the last 28 years. Use supplemental pages if necessary and ensure all dates are consecutive.
6. In the Signature Area, ensure that both applicants sign in the designated boxes and date their signatures appropriately. The authorized person must also sign where indicated.

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