Self-Directed Service Termination Form

This form is used as a communication and process coordination tool when Support Brokerage and/or Fiscal Intermediary (FI) services are terminating, changing, or transferring, and/or when a Participant is transferring between OPWDD Developmental Disabilities Regional Field Offices (DDRFO).

This form does not approve or deny services and does not by itself remove authorization of services from the participant’s Self-Direction Budget 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 Termination/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)

 

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Updated 06/05/26.