Submit Request for Provider

This option is for those individuals/families that choose not to contact providers using the Provider Book or DODD Provider Search Website. Your SSA/EIS will help you put together your Request for Provider (RFP) or you may submit your RFP directly to DCBDD by completing the information below. Once your RFP is submitted, it will be reviewed and may be edited to meet HIPAA privacy requirements and/or people first language.

* required fields - Confidential information is for Board eyes only.

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RFP Title - HIDDEN

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Name of person submitting this RFP - Hidden

Name of person submitting this RFP(Required)

First Last

Email(Required)

Phone(Required)

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Name of eligible individual - Hidden

Name of eligible individual(Required)

First Last

Select Service Department(Required)

Early Intervention Associate(Required)

Service and Support Administrator (SSA)(Required)

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Service Type (old)

Service Type(Required)

Funding Type(Required)

What area of Delaware County will services be provided?(Required)

Requested day for service?

Description of Service Needed(Required)

When writing your RFP it is best to be specific about the services and providers you are looking for. Ask yourself... Do I prefer an agency provider or independent provider? What days and times will I need services? Is there any type of specific training I prefer my providers to have? Will my provider need to be able to provide transportation? If you are requesting therapy services, would you like those to be provided in your home or a clinic?

Special instructions (optional, will not be included in the RFP)

Responses should be received by:(Required)

Post my RFP on the DCBDD website?(Required)

Yes

Email to Providers?(Required)

Yes

Have Service Providers Contact Me Directly?(Required)

Yes

If you enter "no" your support administrator will be contacted with the responses.

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Name

First Last

Submit Request for Provider

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