ODDS Eligibility Consultation Submission Form

Date to ODDS: Click or tap to enter a date.	Response needed by: Click or tap to enter a date.
CDDP and ES name:
Applicant legal name (include alias if listed in eXPRS):	Prime: Click or tap here to enter text.	Date of Birth:Click or tap to enter a date.
Is the individual DD eligible now or have they been eligible?	Yes ☐ No ☐
If eligibility ended, when? Click or tap to enter a date.	Include notes, notices, explanation
Date of Application: 12/29/2020
Reason for Consultation Request: Policy/OAR additional guidance ☐ Process/Procedure guidance ☐ Diagnosis not listed in eXPRS: ☐ Other Genetic Condition/OHI (list diagnoses): Other (explain): Click or tap here to enter text.
Required documents attached: ☐ All psychological assessments ☐ All adaptive assessments ☐ Medical evaluations ☐ Developmental records and history ☐ School assessments ☐ Mental health assessments	☐ Hospital records ☐ Other Specialty Reports (i.e.: Genetic Report; Neurology for Seizures/Epilepsy, etc.) ☐All eligibility statements ☐ All written communication regarding the eligibility decision (letters of notice, progress notes, emails) ☐ Citizen status documents

See D&E Consultation Worker Guide for Eligibility Specialist procedures and example consultation questions.