March 20, 2023

DVU Brief:

099 standard vendorization.

Enclosures A-I

 

Directive

March 20, 2023

TO: REGIONAL CENTER EXECUTIVE DIRECTORS

SUBJECT: SELF-DETERMINATION PROGRAM: STANDARDIZED VENDORIZATION PACKET FOR PRE-ENROLLMENT SUPPORTS

The purpose of this correspondence is to provide regional centers with the Department of Developmental Services (Department) approved standardized vendorization packet for Self-Directed Supports (Service Code 099), as described in the Department’s December 2, 2022 guidance. Regional centers shall require only the documents provided in the enclosed packet for all potential vendors interested in providing Self-Directed Supports. Any deviation from the use of this packet requires advance approval from the Department. The packet includes the following documents:

1. Vendor Packet Checklist
2. General Self-Directed Supports Qualifications and Agreement Form
3. Financial Management Services Self-Directed Supports Qualifications and Agreement Form
4. DS1890 Vendor Application with sample form and FAQs
5. DS1891 Applicant/Vendor Disclosure Statement with sample form
6. Conflict of Interest Form with FAQs
7. Business Associate Agreement/HIPAA Form with FAQs
8. Home and Community-Based Services Provider Agreement Form with sample form
9. W-9 Request for Taxpayer Identification Number and Certification

Information about Self-Directed Supports can be found in the Department’s July 28, 2022 guidance.

If Self-Determination Program participants, family members, or prospective vendors have questions regarding this correspondence, they should contact their regional center.

Questions from regional centers should be directed to sdp@dds.ca.gov.

 

Sincerely,

Original Signed by:

VICKI L. SMITH, Ph.D.

Deputy Director

Policy and Program Development Division Enclosure

 

cc: Regional Center Administrators

Regional Center Directors of Consumer Services

Regional Center Community Services Directors

Association of Regional Center Agencies

State Council on Developmental Disabilities

Nancy Bargmann, Department of Developmental Services

Brian Winfield, Department of Developmental Services

Carla Castañeda, Department of Developmental Services

Jim Knight, Department of Developmental Services

Ernie Cruz, Department of Developmental Services

Suzy Requarth, Department of Developmental Services

 

Link to Directive 

Self-Determination Program: Standardized Vendorization Packet for Pre-Enrollment Supports (English)

Self-Determination Program: Standardized Vendorization Packet for Pre-Enrollment Supports (Spanish)

Self-Determination Program: Standardized Vendorization Packet for Pre-Enrollment Supports (Korean)

 

Enclosures:

Enclosure A – Vendor Packet Checklist

Enclosure B – General SD Supports Qualifications and Agreement Form

Enclosure C – FMS SD Supports Qualifications and Agreement Form

Enclosure D – Vendor Application with Sample Form and FAQs

Enclosure E – Applicant Vendor Disclosure Statement with Sample Form

Enclosure F – Conflict of Interest Form with FAQs

Enclosure G – Business Associate Agreement/HIPAA Form with FAQs

Enclosure H – HCBS Provider Agreement with Sample Form

Enclosure I – Form W-9 (Request for Taxpayer Identification Number and Certification)