ࡱ> 69/012345 Gbjbj00 2ZgZgA  8ls&~#3(F3F3F3z4x6$8r r r r r r r$ vx-rq8z4z488-rF3F34sOOO8FF3F3rO8rOOceF3Zd^^8jqdqs0sd6DyZ9 Dy,eenDy+f 88O88888-r-r\D2 888s8888Dy888888888 X p: Office of Developmental Disability Services Request for Eligibility DeterminationFor CDDP office use onlyDate receivedCDDP receiving form FORMCHECKBOX  Initial application  FORMCHECKBOX  Reapplication FORMTEXT       FORMTEXT      Title XIX Medicaid (OSIPM or MAGI)OHP number or OHP referral datePrime number  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMTEXT       FORMTEXT       Applicant information (please print)Last nameFirst nameMiddle initialGender FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Social Security numberBirthdateBirthplaceMarital status FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Current addressCityStateZIP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Mailing address (if different)CityStateZIP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Primary phone numberEmail address (optional) FORMTEXT       FORMTEXT       Primary contact, custodial parent or guardian (if applicable)NameRelationship (for example., custodial parent, guardian) FORMTEXT       FORMTEXT      AddressCityStateZIP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Primary phone numberEmail address (optional) FORMTEXT       FORMTEXT      Does the applicant have a court-appointed guardian? FORMCHECKBOX  Yes  FORMCHECKBOX  NoAppointed guardian s name, address and phone number (note if same as above) FORMTEXT      Does the applicant have a health care representative? ORS 127.505  FORMCHECKBOX  Yes  FORMCHECKBOX  NoHealth care representative s name, address and phone number (note if same as above) FORMTEXT       Referral to Community Developmental Disabilities Program (CDDP)Name and title of individual who referred applicantPhone number FORMTEXT       FORMTEXT      Has the applicant ever received, or applied for, services from a disability-related program in Oregon or any State outside of Oregon? FORMCHECKBOX  Yes  FORMCHECKBOX  NoPlease list Oregon County or other State(s) FORMTEXT      Applicant s preferred communication format (OAR 943-070-0040)In what language do you want us to speak with you?  FORMTEXT      In what language do you want us to write to you?  FORMTEXT      Do you need an interpreter (including sign language)?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoOther communication needs: FORMTEXT       Applicant s ethnicity (OAR 943-070-0030)Ethnicity (Select as many boxes as apply) FORMCHECKBOX  Hispanic/Latino  FORMCHECKBOX  Cuban  FORMCHECKBOX  Mexican  FORMCHECKBOX  Puerto Rican  FORMCHECKBOX  South or Central American  FORMCHECKBOX  Other FORMCHECKBOX  Non-Hispanic FORMCHECKBOX  Unknown FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  Decline to answerApplicant s race (OAR 943-070-0030)Race (Select as many boxes as apply) FORMCHECKBOX  American Indian or Alaska Native  FORMCHECKBOX  Alaska Native  FORMCHECKBOX  American Indian  FORMCHECKBOX  Canadian Inuit, Metis or First Nation  FORMCHECKBOX  Indigenous Mexican, Central American, or South American  FORMCHECKBOX  Other American Indian FORMCHECKBOX  Asian  FORMCHECKBOX  Asian Indian  FORMCHECKBOX  Chinese  FORMCHECKBOX  Filipino/a  FORMCHECKBOX  Hmong  FORMCHECKBOX  Japanese  FORMCHECKBOX  Korean  FORMCHECKBOX  Laotian  FORMCHECKBOX  South Asian  FORMCHECKBOX  Vietnamese  FORMCHECKBOX  Other Asian FORMCHECKBOX  White  FORMCHECKBOX  Eastern European  FORMCHECKBOX  Middle Eastern  FORMCHECKBOX  Northern African  FORMCHECKBOX  Slavic  FORMCHECKBOX  Western European  FORMCHECKBOX  Other White FORMCHECKBOX  African American or Black  FORMCHECKBOX  African  FORMCHECKBOX  African American  FORMCHECKBOX  Caribbean  FORMCHECKBOX  Other Black FORMCHECKBOX  Native Hawaiian or Pacific Islander  FORMCHECKBOX  Guamanian or Chamorro  FORMCHECKBOX  Native Hawaiian  FORMCHECKBOX  Samoan  FORMCHECKBOX  Other Pacific Islander FORMCHECKBOX  Other:  FORMTEXT       FORMCHECKBOX  Unknown FORMCHECKBOX  Decline to answerDevelopmental disabilitiesDescribe your disability and the age at which it was first observed FORMTEXT      Intellectual disability Observed or diagnosed conditionsIf diagnosed, list provider and date FORMCHECKBOX Intellectual Disability FORMTEXT       FORMCHECKBOX Global Developmental Delay FORMTEXT       FORMCHECKBOX Delayed milestones FORMTEXT      Other developmental disabilityObserved or diagnosed conditionsIf diagnosed, list provider and date FORMCHECKBOX Autism Spectrum Disorder  FORMTEXT       FORMCHECKBOX Cerebral Palsy FORMTEXT       FORMCHECKBOX Down Syndrome FORMTEXT       FORMCHECKBOX Epilepsy FORMTEXT       FORMCHECKBOX Prenatal exposure to drugs, alcohol, or other toxin(s) FORMTEXT       FORMCHECKBOX Tourette s Disorder FORMTEXT       FORMCHECKBOX Acquired/Traumatic Brain Injury FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT      Other conditionsObserved or diagnosed conditionsIf diagnosed, list provider and date FORMCHECKBOX Attention-Deficit/Hyperactivity Disorder  FORMTEXT       FORMCHECKBOX Depressive Disorder FORMTEXT       FORMCHECKBOX Language Disorder FORMTEXT       FORMCHECKBOX Bipolar or Personality Disorder FORMTEXT       FORMCHECKBOX Post-traumatic Stress Disorder FORMTEXT       FORMCHECKBOX Specific Learning Disorder FORMTEXT       FORMCHECKBOX Substance-Related Disorder FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMTEXT       Medical providersPrimary care physician or clinicLocationPhone number FORMTEXT       FORMTEXT       FORMTEXT      Dentist or clinicLocationPhone number FORMTEXT       FORMTEXT       FORMTEXT      Preferred hospitalLocationPhone number FORMTEXT       FORMTEXT       FORMTEXT       Disability evaluationsPlease list professionals who have evaluated your disabilities. Include psychologists, neuropsychologists, psychiatrists, neurologists, developmental pediatricians, geneticists and mental health providers. For example, list professionals you have seen for an IQ test, psychological evaluation, medical or genetic evaluation of your disability, or mental health assessment. DateName of professional or clinicType of evaluation FORMTEXT       FORMTEXT       FORMTEXT      Location (provide address if known)Phone number FORMTEXT       FORMTEXT      DateName of professional or clinicType of evaluation FORMTEXT       FORMTEXT       FORMTEXT      Location (provide address if known)Phone number FORMTEXT       FORMTEXT      DateName of professional or clinicType of evaluation FORMTEXT       FORMTEXT       FORMTEXT      Location (provide address if known)Phone number FORMTEXT       FORMTEXT      DateName of professional or clinicType of evaluation FORMTEXT       FORMTEXT       FORMTEXT      Location (provide address if known)Phone number FORMTEXT       FORMTEXT      Have you ever been admitted to a treatment center or hospital for psychiatric or medical treatment? FORMCHECKBOX  Yes  FORMCHECKBOX  NoDateName and location of facility or hospital name FORMTEXT       FORMTEXT       Other service agencies (examples include: Child Welfare, Self-Sufficiency, Vocational Rehabilitation, Mental Health)Start/end dateAgency or provider locationContact s name FORMTEXT       FORMTEXT       FORMTEXT      Start/end dateAgency or provider locationContact s name FORMTEXT       FORMTEXT       FORMTEXT      Start/end dateAgency or provider locationContact s name FORMTEXT       FORMTEXT       FORMTEXT       Medical insuranceApplicant s health insurance FORMCHECKBOX Private Health Insurance FORMCHECKBOX Oregon Health Plan FORMCHECKBOX MedicareCarrier  FORMTEXT      OHP/Medicaid #  FORMTEXT      Plan #  FORMTEXT       FORMCHECKBOX I do not currently have health insurance. Eligibility for certain developmental disability services is dependent on your eligibility for Medicaid. If you have not yet applied, talk with the CDDP about how to apply.Have you applied for medical assistance? 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hq#0h;;0jhbdh{/CJOJQJU^JmHnHuU%jhbdh{/CJOJQJU^J+jhbdh{/CJOJQJU^Jhbdh{/CJOJQJ^J      FORMCHECKBOX Other:  FORMTEXT       Social SecurityIndividuals with disabilities may qualify for one of two federal disability programs: Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). The Social Security Administration (SSA) manages these programs. Have you applied for Social Security benefits? FORMCHECKBOX  Yes  FORMCHECKBOX  NoDate of application FORMTEXT      Do you currently receive Social Security benefits? FORMCHECKBOX  Yes  FORMCHECKBOX  NoStart date FORMTEXT       FORMCHECKBOX Supplemental Security Income (SSI)Amount FORMTEXT       FORMCHECKBOX Social Security Disability Insurance (SSDI)Amount FORMTEXT      Have you ever lost SSI due to earnings, receiving a Social Security benefit from a parent or a Cost of Living Allowance increase? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf you have not applied for SSI/SSDI benefits, you can learn more about social security benefits on the  HYPERLINK "http://www.ssa.gov/disability/" Social Security Website. Contact your  HYPERLINK "https://secure.ssa.gov/ICON/main.jsp" local SSA office to apply. These resources may be helpful: Understanding SSI:  HYPERLINK "http://www.socialsecurity.gov/ssi/text-income-ussi.htm" http://www.socialsecurity.gov/ssi/text-income-ussi.htm SSI Payment Amounts:  HYPERLINK "http://www.ssa.gov/oact/cola/SSI.html" http://www.ssa.gov/oact/cola/SSI.htmlEducational historyName of current school or last school attendedStart dateEnd date FORMTEXT       FORMTEXT       FORMTEXT      City and state FORMTEXT      Name of former schoolStart dateEnd date FORMTEXT       FORMTEXT       FORMTEXT      City and state FORMTEXT      Have you ever received special education services at any school (for example, early intervention, IEP, or 504 plan)? FORMCHECKBOX  Yes  FORMTEXT      Did you graduate from high school? FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, what type of diploma did you receive (or do you expect to receive)?  FORMCHECKBOX  Regular FORMCHECKBOX  GED  FORMCHECKBOX  Unknown FORMCHECKBOX  Modified  FORMCHECKBOX  Certificate Legal historyDo you have a criminal record or juvenile court record? FORMCHECKBOX  Yes  FORMCHECKBOX  NoState and county of offenseNature of offense FORMTEXT       FORMTEXT      Parole/Probation officerPhone number FORMTEXT       FORMTEXT      Other information FORMTEXT       Why we need your social security numberFederal laws, 42 USC 1320b-7(a)&(b), 42 CFR 435.910, 42 CFR 435.920, and 42 CFR 457.340(b), as well as OAR 461-120-0210, require applicants to provide ODHS/OHA a SSN on applications for medical benefits, except as provided in OAR 461-120-0210. ODHS and OHA will use your SSN to help decide if you are eligible for benefits. ODHS and OHA may use your SSN to match the information on your application with records provided to, or created by, other state and federal programs and agencies, such as the IRS, Medicaid, Social Security and Employment Department. ODHS and OHA may also use your SSN, at the request of funding agencies, to prepare aggregate data or reports about the programs you apply for and receive benefits from. Specifically, ODHS and OHA may use or disclose your SSN to: operate the program you apply for or receive benefits from; conduct quality assessment and improvement activities; verify the correct amount of payments and conduct business with providers; and recover overpaid benefits. Notification of eligibility decisionIf you would like a copy of the CDDP s eligibility decision notice sent to anyone besides yourself, you must provide the name and address of the person. The CDDP must have a written authorization in order to release information and to send a notice to anyone other than the applicant or legal guardian.Name Relationship to applicant (for example, guardian, representative) FORMTEXT       FORMTEXT      AddressCityStateZIP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       SignatureBy signing below, I agree that the information contained in this application is true and correct, whether given by me or a representative. I also confirm that I have received and reviewed the notice of rights on the following page.SignatureDatePrint name FORMTEXT      Relationship FORMCHECKBOX Self (adult applicant) FORMCHECKBOX Adult s court-appointed guardian FORMCHECKBOX Minor s custodial parent or legal guardian FORMCHECKBOX  FORMTEXT       Notice of rightsYou are requesting services from the Oregon developmental disability system. Participation is voluntary; you may withdraw this request at any time. The Oregon Department of Human Services (ODHS) does not discriminate. ODHS serves every applicant that qualifies for services, and ODHS will not treat any applicant differently because of age, race, gender, color, national origin, religion, political beliefs, disability or sexual orientation. If you believe ODHS treated you unfairly, you may file a complaint with the Governor s Advocacy Office (1-800-442-5238). The CDDP and ODHS will protect your information and records in accordance with the privacy and security polices of ODHS, ORS 179.505 and ORS 179.507. The CDDP needs your authorization to request and release records related to your disability. Intake is complete when you sign and submit this form to the CDDP and sign authorizations for the CDDP to obtain the records that you do not provide. The CDDP will collaborate with you to assemble a complete application for services within 90 days. The CDDP may contact you to request an extension of the decision timeline beyond 90 days, if the CDDP needs more documents to make an eligibility decision. If the CDDP needs more information to determine the existence of a developmental disability, the CDDP may ask you to attend a diagnostic evaluation, in accordance with ORS 410.060 and 427.105. The CDDP must receive a completed application before making an eligibility decision. A completed application includes this form, as well as documents and records necessary to make an eligibility decision. When the CDDP receives all the documents related to your disability (as described in OAR 411-320-0080(1)), the CDDP will send you a written decision notice. Intake and complete application are defined in OAR 411-320-0020. The CDDP s written decision notice will contain a notice of hearing rights. If you disagree with the CDDP s decision, you may request a contested case hearing, as described in ORS Chapter 183 and OAR 411-318-0025. You may request a contested case hearing by filling out an Administrative Hearing Request Form ( HYPERLINK "https://apps.state.or.us/Forms/Served/se0443dd.doc" SDS 0443DD), or by making a verbal request for a hearing to a CDDP or ODHS employee. ODHS must receive a hearing request within 90 days of the notice of eligibility decision. You may appoint another person to represent you or request a hearing on your behalf, including legal counsel or a relative, friend, or other spokesman. You may identify your representative when you request a hearing.     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MAGI)DNoVFor CDDP office use only: Check here if this is not Title XIX Medicaid (OSIPM or MAGI)0DOHP number or OHP referral dateDFor CDDP office use only: Enter OHP number or OHP referral date hereD Prime number1For CDDP office use only: Enter Prime number here$$If!vh#v#vw#v :V lh  t6,,555/ / / / pytB?$$If!vh#v +:V l  t 0,5p ytxg$$If!vh#v&#v #v\#v:V l   t(0,5l595W5/ p(yteD Last name+Applicant information: Enter last name hereD First nameEnter First name hereDMiddle initialEnter Middle initial hereDGenderEnter Gender here$$If!vh#v&#v #v\#v:V lh t0,5l595W5/ p(yt9f$$If!vh#v #v#v#v:V l   t(0,5H555/ p(yt]0DSocial security number!Enter Social security number hereD BirthdateEnter Birthdate hereD BirthplaceEnter Birthplace hereDMarital statusEnter Marital status here$$If!vh#v #v#v#v:V lh t0,5H555/ p(yt]0$$If!vh#v^#v #v:#ve:V l   t(0,5V5`55/ p(ytZDCurrent addressEnter Current address hereDCityEnter current address City hereDState Enter current address State hereDZIP#Enter current address ZIP code here$$If!vh#v^#v #v:#ve:V lh t0,5V5`55/ p(ytZ$$If!vh#v^#v #v:#ve:V l   t(0,5V5`55/ p(ytZDMailing address (if different))Enter Mailing address here, iif differentDCityEnter mailing address City hereDState Enter mailing address State hereDZIP#Enter mailing address ZIP code here$$If!vh#v^#v #v:#ve:V lh t0,5V5`55/ p(ytZ$$If!vh#v^#v:V l   t0,5V52 / pyt]0DPrimary phone numberEnter Primary phone number hereDEmail address (optional)#Enter Email address here (optional)$$If!vh#v^#v:V lh t0,5V52 / pyt]0y$$If!vh#v +:V l  t ,5/ p ytxg$$If!vh#v_#v:V l   t,5V52 /  pyt]0DNameNPrimary contant, custodial parent or guardian (if applicable): Enter name hereJD/Relationship (e.g., custodial parent; guardian)AEnter Relationship here (for example, custodial parent; guardian)u$$If!vh#v_#v:V lh t,5V52 / p yt]0$$If!vh#v_#v #v:#vg:V l   t(0,5V5_55/ p(yt #DAddressEnter Address hereDCityEnter city hereDStateEnter State hereDZIPEnter ZIP code here$$If!vh#v_#v #v:#vg:V lh t0,5V5_55/ p(ytZ$$If!vh#v_#v:V l   t0,5V52 / pyt]0DPrimary phone numberEnter Primary phone number hereDEmail address (optional)#Enter Email address here (optional)$$If!vh#v_#v:V lh t0,5V52 / pyt]0DYes :Check here if the applicant has a court-appointed guardianDNoDCheck here if the applicant does not have a court-appointed guardian$$If!vh#v"#v:V l  t ,55/  pyt-b$$If!vh#v +:V l   t 0,5/ p yteDJAppointed guardian s name, address, & phone number (note if same as above)VEnter appointed guardian s name, address and phone number here (note if same as above)$$If!vh#v +:V lh t0,5/ p yteDYesJCheck here if the applicant has a health care representative (ORS 127.505)DNoTCheck here if the applicant does not have a health care representative (ORS 127.505)$$If!vh#v"#v:V l  t ,55/ pyte$$If!vh#v +:V l   t 0,5/ p yteDRHealth care representative s name, address, & phone number (note if same as above)^Enter Health care representative s name, address and phone number here (note if same as above)$$If!vh#v +:V lh t0,5/ p ytey$$If!vh#v +:V l  t ,5/ p ytxg$$If!vh#v #v :V l   t,55/  pyt5}HD1Name & title of individual who referred applicant>Enter Name and title of individual who referred applicant hereD Phone number<Enter Phone number of individual who referred applicant hereu$$If!vh#v #v :V lh t,55/ p yt5}zDYesCheck here if the applicant has ever received, or applied for, services from a disability-related program in Oregon or any other stateDNoCheck here if the applicant has not ever received, or applied for, services from a disability-related program in Oregon or any other state$$If!vh#v"#v:V l  t ,55/  pyt)tDText38+Please list Oregon County or other State(s)tList the Oregon county or other states where the applicant received or applied for a disability related program here$$If!vh#v#v+:V l  t ,,5 5 / pyt]0y$$If!vh#v +:V l  t ,5/ p ytxgVDText403In what language do you want us to speak with you? =Enter what language you want us to use to speak with you here$$If!vh#vF#v :V l  t 0,5I 5?pyt.OBD1In what language do you want us to write to you? ;Enter what language you want us to use to write to you here$$If!vh#vF#v :V l  t 0,5I 5?pyt.ODYesCCheck here if you need an interpreter (including for sign language)DNoJCheck here if you do not need an interpreter (including for sign language)$$If!vh#vF#v :V l  t 0,,5I 5?pytdXDOther communication needs:(Enter any other communication needs here$$If!vh#v#v:V l  t0,5 5{ pyt.O$$If!vh#v+:V l  t 06,5p yth$$If!vh#v+:V l   t 06,5/ p yth DCheck13Hispanic/Latino<Check here if Hispanic/Latino describes your ethnic identityDCheck10Cuban2Check here if Cuban describes your ethnic identityDMexican4Check here if Mexican describes your ethnic identityD Puerto Rican 9Check here if Puerto Rican describes your ethnic identity(DSouth or Central American FCheck here if South or Central American describes your ethnic identityDOtherGCheck here if you identify with another Hispanic/Latino ethnic identityDCheck5 Non-Hispanic9Check here if Non-Hispanic describes your ethnic identity$$If!vh#v#v:V l4 t06+,5(5` / /  p ythDCheck15Unknown-Check here if your ethnic identity is Unknown$$If!vh#v#v:V l4 t06+,5(5` / /  p ythDOther:7Check here if you identify with another ethnic identityDText1Other:Enter your ethnicty here$$If!vh#v#v:V l4 t06+,5(5` / /  p ythDDecline to answer=Check here ifyou decline to answer about your ethnic identity$$If!vh#v#v:V l4 t06+,5(5` / / /  p yth$$If!vh#v+:V l  t 06,5p yth$$If!vh#v+:V l   t 06,5/ / p ythBD American Indian or Alaska NativeMCheck here if American Indian or Alaska Native describes your racial identityD Alaska Native:Check here if Alaska Native describes your racial identityDAmerican Indian <Check here if American Indian describes your racial identityVD%Canadian Inuit, Metis or First NationRCheck here if Canadian Inuit, Metis or First Nation describes your racial identityD7Indigenous Mexican, Central American, or South AmericandCheck here if Indigenous Mexican, Central American, or South American describes your racial identity(DOther American IndianKCheck here if you identify with a different American Indian racial identityDAsian2Check here if Asian describes your racial identityD Asian Indian9Check here if Asian Indian describes your racial identityDChinese4Check here if Chinese describes your racial identityD Filipino/a7Check here if Filipino/a describes your racial identityDHmong2Check here if Hmong describes your racial identityDJapanese5Check here if Japanese describes your racial identityDKorean3Check here if Korean describes your racial identityDLaotian4Check here if Laotian describes your racial identityD South Asian8Check here if South Asian describes your racial identityD Vietnamese7Check here if Vietnamese describes your racial identityD Other AsianACheck here if you identify with a different Asian racial identityDWhite2Check here if White describes your racial identityDEastern European=Check here if Eastern European describes your racial identityDMiddle Eastern;Check here if Middle Eastern describes your racial identityDNorthern African=Check here if Northern African describes your racial identityDSlavic3Check here if Slavic describes your racial identityDWestern European=Check here if Western European describes your racial identityD Other WhiteACheck here if you identify with a different White racial identity$$If!vh#v #v,#v:V l$ t065D55a/ /  pyth&DAfrican American or BlackFCheck here if African American or Black describes your racial identityDAfrican4Check here if African describes your racial identityDAfrican American=Check here if African American describes your racial identityD Caribbean6Check here if Caribbean describes your racial identityD Other BlackACheck here if you identify with a different Black racial identityND#Native Hawaiian or Pacific IslanderPCheck here if Native Hawaiian or Pacific Islander describes your racial identityDGuamanian or ChamorroBCheck here if Guamanian or Chamorro describes your racial identityDNative Hawaiian <Check here if Native Hawaiian describes your racial identityDSamoan3Check here if Samoan describes your racial identity,DOther Pacific IslanderLCheck here if you identify with a different Pacific Islander racial identityDOther:DCheck here if your racial identity is other than what is listed hereDOther:Enter your racial identity here%$$If!vh#v #v,#v:V l4 t06++,5D55a/ / / / / / pythDUnknown-Check here if your racial identity is unknown$$If!vh#v #v,#v:V l4 t06++,5D55a/ / / pythDDecline to answer>Check here if you decline to answer about your racial identity$$If!vh#v #v,#v:V l4 t06++,5D55a/  / / pyth$$If!vh#v*:V l  t 06,5p yth$$If!vh#v*:V l   t 06,5/ p ythDCDescribe your disability and the age at which it was first observedHDescribe your disability and the age at which it was first observed here$$If!vh#v*:V l t065/ / p yth$$If!vh#v*:V l  t 06,5p yth$$If!vh#v#v:V l   t06,5 5 / 2 pyth2DCheck22Intellectual DisabilityGCheck here if an Intellectual Disability has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / / pyth<DCheck25Global Developmental DelayICheck here if a Global Developmental Delay has been observed or diagnosedDText36%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth DDelayed milestones@Check here if Delayed milestones have been observed or diagnosedDText121%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth$$If!vh#v*:V l  t 06,5/ p yth$$If!vh#v#v:V l   t06,5 5 / 2 pytr$DAutism Spectrum Disorder ECheck here if Autism Spectrum Disorder has been observed or diagnosedDText3%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / / pythDCheck23Cerebral Palsy;Check here if Cerebral Palsy has been observed or diagnosedDText4%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythDCheck24 Down Syndrome:Check here if Down Syndrome has been observed or diagnosedDText31%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythDEpilepsy5Check here if Epilepsy has been observed or diagnosedDText32%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythD6Prenatal exposure to drugs, alcohol, or other toxin(s)cCheck here if Prenatal exposure to drugs, alcohol, or other toxin(s) has been observed or diagnosedDText75%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythDTourette s Disorder@Check here if Tourette s Disorder has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth>DAcquired/Traumatic Brain InjuryLCheck here if Acquired/Traumatic Brain Injury has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythDeMCheck here if another developmental disability has been observed or diagnosedD+Specify other developmental disability hereD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth$$If!vh#v*:V l  t 06,5p yth$$If!vh#v#v:V l   t06,5 5 / 2 pytrdD)Attention-Deficit/Hyperactivity Disorder UCheck here if Attention-Deficit/Hyperactivity Disorder has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / / pythDDepressive Disorder@Check here if Depressive Disorder has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pythDCheck21Language Disorder@Check here if a Language Disorder has been observed or diagnosedDText2%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth>DBipolar or Personality DisorderLCheck here if Bipolar or Personality Disorder has been observed or diagnosedDText37%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth8DPosttraumatic Stress DisorderKCheck here if Post-traumatic Stress Disorder has been observed or diagnosedDText33%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth.DSpecific Learning DisorderICheck here if a Specific Learning Disorder has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pyth.DSubstance-Related DisorderICheck here if a Substance-Related Disorder has been observed or diagnosedD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / pyt*oDe>Check here if another condition has been observed or diagnosedDSpecify other condition hereD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / pyt*oDe>Check here if another condition has been observed or diagnosedDSpecify other condition hereD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / / pyt*oDe>Check here if another condition has been observed or diagnosedDSpecify other condition hereD%If diagnosed, list provider and date-If diagnosed, list the provider and date here$$If!vh#v#v#v:V l t06,,555 / / pytav|$$If!vh#v +:V l  t 6,5/ p yt5}$$If!vh#v#v#v :V l   t6,555/  pyt9fD Primary care physician or clinic+Enter Primary care physician or clinic hereDLocation4Enter primary care physician or clinic location hereD Phone number8Enter primary care physician or clinic phone number here$$If!vh#v#v#v :V lh t6,555/ p yt9f$$If!vh#v#v#v :V l   t6,555/  pyt9fDDentist or clinicEnter Dentist or clinic hereDLocation%Enter dentist or clinic location hereD Phone number)Enter dentist or clinic phone number here$$If!vh#v#v#v :V lh t6,555/ p yt9f$$If!vh#v#v#v :V l   t6,555/  pyt9fDPreferred hospitalEnter Preferred hospital hereDLocation&Enter preferred hospital location hereD Phone number*Enter preferred hospital phone number here$$If!vh#v#v#v :V lh t6,555/ p yt9f|$$If!vh#v +:V l  t 6,5/ p yt5}|$$If!vh#v +:V lP  t 6,5/  p yt*o$$If!vh#v #v(#v:V l   t6,55 5/  pytVDDate(Enter date of disability evaluation hereJDName of professional or clinicREnter name of professional or clinic that performed the disability evaluation hereDType of evaluationEnter type of evaluation here$$If!vh#v #v(#v:V lh t6,55 5/ pyt#/-$$If!vh#v3#v:V l   t6,5 5/  pyt5}@D#Location (provide address if known)HEnter location of professional or clinic here (provide address if known)D Phone number1Enter phone number of professional or clinic herex$$If!vh#v3#v:V lh t6,5 5/ p yt5}$$If!vh#v #v(#v:V l   t6,55 5/  pyt#/-DDate(Enter date of disability evaluation hereJDName of professional or clinicREnter name of professional or clinic that performed the disability evaluation hereDType of evaluationEnter type of evaluation here$$If!vh#v #v(#v:V lh t6,55 5/ pyt#/-$$If!vh#v3#v:V l   t6,5 5/  pyt5}@D#Location (provide address if known)HEnter location of professional or clinic here (provide address if known)D Phone number1Enter phone number of professional or clinic herex$$If!vh#v3#v:V lh t6,5 5/ p yt5}$$If!vh#v #v(#v:V l   t6,55 5/  pyt#/-DDate(Enter date of disability evaluation hereJDName of professional or clinicREnter name of professional or clinic that performed the disability evaluation hereDType of evaluationEnter type of evaluation here$$If!vh#v #v(#v:V lh t6,55 5/ pyt#/-$$If!vh#v3#v:V l   t6,5 5/  pyt5}D"Location (provide address if known"Location (provide address if knownD Phone number1Enter phone number of professional or clinic herex$$If!vh#v3#v:V lh t6,5 5/ p yt5}$$If!vh#v #v(#v:V l   t6,55 5/  pyt#/-DDate(Enter date of disability evaluation hereJDName of professional or clinicREnter name of professional or clinic that performed the disability evaluation hereDType of evaluationEnter type of evaluation here$$If!vh#v #v(#v:V lh t6,55 5/ pyt#/-$$If!vh#v3#v:V l   t6,5 5/  pyt5}D"Location (provide address if known"Location (provide address if knownD Phone number1Enter phone number of professional or clinic herex$$If!vh#v3#v:V lh t6,5 5/ p yt5}PDYes pCheck here if you have ever been admitted to a treatment center or hospital for psychiatric or medical treatmentNDNoqCheck here if you have never been admitted to a treatment center or hospital for psychiatric or medical treatment$$If!vh#v"#v :V l@  t6,5q5/  pyt5}$$If!vh#v #v$:V l   t6,55/  pyt#/-,DDate]Enter date of admittance to treatment center or hospital for psychiatric or medical treatment.D.Name and location of facility or hospital name4Enter name and location of facility or hospital herex$$If!vh#v #v$:V lh t6,55/ p yt#/-|$$If!vh#v +:V l  t 6,5/ p yt)t$$If!vh#v#v#vL:V l   t6,55 5}/  pytlxDStart/end dateyEnter start and end date of sevices by another agency (such as Child Welfare, Self-Sufficiency, VR or Mental Health) hereDAgency/provider location&Enter agency or provider location hereDContact s name Enter agency contact s name here$$If!vh#v#v#vL:V lh t6,55 5}/ pytl$$If!vh#v#v#vL:V l   t6,55 5}/  pytlxDStart/end dateyEnter start and end date of sevices by another agency (such as Child Welfare, Self-Sufficiency, VR or Mental Health) hereDAgency/provider location&Enter agency or provider location hereDContact s name Enter agency contact s name here$$If!vh#v#v#vL:V lh t6,55 5}/  pytl$$If!vh#v#v#vL:V l   t6,55 5}/  pytlxDStart/end dateyEnter start and end date of sevices by another agency (such as Child Welfare, Self-Sufficiency, VR or Mental Health) hereDAgency/provider location&Enter agency or provider location hereDContact s name Enter agency contact s name here$$If!vh#v#v#vL:V lh t6,55 5}/ pytl|$$If!vh#v +:V l  t 6,5/ p ytG$$If!vh#v +:V l   t 06,5/ p ytGD Private Health Insurance Carrier/Check here if you have private health insurance>D!Oregon Health Plan OHP/Medicaid #JCheck here if your health insurance coverage is through Oregon Health PlanDMedicare Plan #@Check here if your health insurance coverage is through Medicare$$If!vh#v#v #v#v#v#v :V l t06,5555d55g/  / / / /  / / / /  / / / p<ytl DText87 Private Health Insurance Carrier+Enter private health insurance carrier here D!Oregon Health Plan OHP/Medicaid #0Enter Oregon Health Plan or Medicaid number hereDMedicare Plan #Enter Medicare Plan number here$$If!vh#v#v #v#v#v#v :V l t06,5555d55g/  / / /  /  / / /  /  / / /  p<ytl*D)I do not currently have health insurance.8Check here if you do not currently have health insurance$$If!vh#v#v(:V l  t06,55/ / /  / pytl$$If!vh#v +:V l  t 06,5/ / p ytGDYes 5Check here if you have applied for medical assistanceDNo8Check here if you have no applied for medical assistance $$If!vh#v#v:V l  t06,5" 5f/ / / / / pytly$$If!vh#v +:V l  t ,5/ p ytG$$If!vh#v +:V l   t 0,5/ p ytGDCheck7 Employment,Check here if you get income from employmentdD.Temporary Assistance for Needy Families (TANF)PCheck here if you get income from Temporary Assistance for Needy Families (TANF)R$$If!vh#v^#vc#vv#v:V l t0,5555s /  / /  /  / / / /  / p(yt\D Trust fund(s)/Check here if you get income from Trust fund(s)DPrivate disability benefits=Check here if you get income from Private disability benefitsD$$If!vh#v^#vc#vv#v:V l t0,5555s / / /  / / / /  / p(ytGDChild support for applicant?Check here if you get income from Child support (for applicant)8D#Adoption or guardianship assistanceECheck here if you get income from Adoption or guardianship assistanceD$$If!vh#v^#vc#vv#v:V l t0,5555s / / /  / / / /  / p(ytGDVeteran s benefits4Check here if you get income from Veteran s benefitsD No income Check here if you have no incomeD$$If!vh#v^#vc#vv#v:V l t0,5555s / / /  / / / /  / p(ytGDOther: 0Check here if you get income from another sourceDOther: Specify other income source hereDOther: 0Check here if you get income from another sourceDOther: Specify other income source hereD$$If!vh#v^#vc#vv#v:V l t0,5555s / / /  / / / /  / p(ytGy$$If!vh#v +:V l  t ,5/ p ytGy$$If!vh#v +:V l  t ,5/  p ytGDYes ;Check here if you have applied for Social Security benefitsDNo?Check here if you have not applied for Social Security benefits$$If!vh#v #v! #v:V l4   t++,,5\ 5%5/ /  pyt$DDate of application7Enter Date of Social Security benefits application here$$If!vh#v #v! #v:V l4  t ++,,5\ 5%5/ pyt$DYes<Check here if you currently receive Social Security benefitsDNoCCheck here if you do not currently receive Social Security benefits$$If!vh#v #v! #v:V l4   t++,,5\ 5%5/ /  pyt$D Start date:Enter the start date of your Social Security benefits here$$If!vh#v #v! #v:V l4  t ++,,5\ 5%5/ pyt$$D"Supplemental Security Income (SSI)<Check here if you receive Supplemental Security Income 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