Self-Directed Service Termination/Transfer Form

This form is completedused as a communication and process coordination tool when a Support BrokerBrokerage and/or Fiscal Intermediary (FI) serviceservices are terminating, changing, or transferring, and/or when a Participant is beingtransferring discontinuedbetween byOPWDD theDevelopmental Self-DirectionDisabilities Participant,Regional theField SupportOffices Broker(DDRFO).

or the FI. 

This form does not approve or deny services and does not by itself remove authorization of the actual serviceservices from the participant’s Self-Direction Participant's self-direction budgetBudget or Life Plan.

The form is used to document notice, establish effective dates, and support coordinated action among the Participant/Representative, providers, Care Manager, and OPWDD.

Per OPWDD, effective 06/04/26, all forms submitted to the Regional Field Office (RFO) must use the revised form (Rev. 5/18/26).

Self-Directed Service TerminationTermination/Transfer Form Rev. 5/18/26 (PDF)

Instructions

The instructions provide guidance on completing and submitting the form and are intended to promote consistent processing of Self-Directed terminations and transfers.

OPWDD's Self-Direction Services Termination/Transfer Form Instructions Rev. 5/18/26 (PDF)

 

---

CreatedUpdated 04/08/06/05/26.