Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In section I, input the consumer's information. Fill in the last name, middle initial, first name, street address, city, state, and ZIP code. Specify the county of residence, date of birth, sex, telephone number, and the last four digits of the social security number.
3. Proceed to section II, where you will provide the details related to the developmental disability diagnosis. State the date of primary diagnosis, primary diagnosis itself, and any other conditions excluding mental illness. Include the secondary and tertiary diagnoses along with their respective dates.
4. At the end of section II, the physician needs to provide their signature, printed name, and contact information, including their telephone number and complete street address.
5. Section III is reserved for office use. Leave this part blank for BDDS staff to complete. Once you have filled in all the necessary information, review the form for accuracy.
6. Finally, ensure to save any changes made to the form, then download or print it for submission. Return the completed form to the consumer to present at their local BDDS office.

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