Massachusetts DDS Eligibility Application

Step 1 of 9

Applicant Information

Basic identifying information about the person applying for DDS services.

Age Range

Between the ages of 5 and 22 years Age 22 and above

Full Name

Last Name *

First Name *

Middle Initial

Date of Birth *

Social Security Number

Address

Street Number

Street Name

Apt / Unit #

City / Town

State

Zip Code

Language Preferences

Preferred spoken language

Preferred written language

Email Address

Are interpreter services needed for hearing? NOTE: Translation and interpretation are free of charge to applicants

Contact Information

Check all contact methods that apply for the applicant.

Primary Phone

Area Code

Number

May we leave a message?

Secondary Phone

Area Code

Number

May we leave a message?

Step 2 of 9

Guardianship

Complete this section only if there is a court-appointed legal guardian. Guardianship papers must be submitted with the application.

Does the applicant have a court-appointed legal guardian?

Guardian Information

Guardian Last Name

Guardian First Name

Relationship to Applicant

Street Address

City / Town

Zip Code

Phone

Step 3 of 9

Current Situation

Information about where the applicant currently lives and their circumstances.

Living at home with family?

Living in a residential school?

Homeless?

Involved with any other state agency?

Currently in a hospital?

Enrolled in school or college?

Step 4 of 9

Type of Application

Select all diagnoses/conditions for which you are applying to DDS. You may select more than one.

Each condition you select will require supporting documentation from a licensed qualified practitioner (Ph.D, Psy.D, MD, etc.).

Closely Related Developmental Condition (ages 5–22 only)

Includes genetic disorders. Requires comprehensive diagnostic report.

Intellectual Disability (ID)

Requires comprehensive diagnostic report including IQ and cognitive testing.

Autism Spectrum Disorder (ASD)

Requires comprehensive diagnostic report from a licensed practitioner.

Prader-Willi Syndrome

Requires genetic testing verifying the Prader-Willi diagnosis.

Smith-Magenis Syndrome

Requires genetic testing verifying the Smith-Magenis diagnosis.

Step 5 of 9

Parent or Immediate Contact

Information about the applicant's parent or primary contact person.

Contact Name & Address

Last Name

First Name

Relationship to Applicant

Street Number

Street Name

Apt / Unit

City

State

Zip

Contact Methods

Primary Phone

Area Code

Number

Leave message?

Secondary Phone

Area Code

Number

Leave message?

Email Address

Step 6 of 9

Authorized Contact

Optionally authorize someone (social worker, teacher, therapist, etc.) to be contacted for the purpose of eligibility. This person cannot be the legal guardian.

Do you want to authorize an additional contact?

Contact Name & Address

Last Name

First Name

Relationship to Applicant

Street Number

Street Name

Apt / Unit

City

State

Zip

Contact Methods

Primary Phone

Area Code

Number

Leave message?

Secondary Phone

Area Code

Number

Leave message?

Email Address

Step 8 of 9

Additional Recipients & Authorization Details

Section IV — Additional Recipients (optional)

Name

Organization

Address

Section V — Certification & Expiration

Authorization expires on * (date or event — must not exceed one year)

Signature — Subject of Information or Guardian

✍️

Click or drag to upload signature image

Date

Print Name

Section VI — Special Authorizations (optional)

Authorize release of HIV/AIDS information (M.G.L. c.111 S.70F) Authorize release of alcohol or drug treatment information (42 CFR Part 2)

If you check either box above, your Section V signature above will also apply to Section VI.

Date

Step 9 of 9

Authorization & Signature

Final authorization for DDS to conduct an eligibility determination.

By signing, you authorize DDS to conduct an eligibility determination. This permission is valid until the application is fully processed, or unless you notify DDS in writing that you revoke it.

Applicant Name for Determination

Applicant's Full Name

Signing as:

Applicant Legal Guardian

Signature

✍️

Click or drag to upload your signature image (PNG/JPG)

This signature will appear on the authorization and eligibility determination pages

Date *

Print Name

Full Address (legal guardian)

Primary Phone

Secondary Phone

Privacy Practices Acknowledgment (page 8)

Facility / Region / Area / Program

✍️

Privacy Acknowledgment Signature (may be same as above)

Personal Representative (only if someone else is signing on behalf of applicant)

Print Name

Role

Witness

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🎉

Your PDF is Ready!

Your completed DDS Eligibility Application has been generated.
Download it, then follow the steps below to submit to your regional office.

Your Regional DDS Office

📍 Determining your region…

How to Submit

📮 Mail or Fax Your Application

Print your downloaded PDF and send the complete packet to your regional office above by mail or fax.

What to include in your packet:

This completed application (all pages)
Birth Certificate
Social Security Card
Health Insurance Card(s) — MassHealth, Medicare, or private insurance
Proof of MA Domicile — e.g. MA Driver's License, MA ID, or utility bill with name and address
Reports documenting your diagnosis (comprehensive diagnostic report from a Ph.D, Psy.D, MD, etc.)
If applicable: Early Intervention / Developmental Profile records
If applicable: IEP and related assessments or 504 Accommodation Plan
If applicable: Adaptive Skills Reports
If applicable: IQ or neuropsychological evaluation report
If applicable: Genetic testing results (for Smith-Magenis, Prader-Willi, or other genetic conditions)
If there is a court-appointed guardian: Guardianship papers
Signed Notice of Privacy Practices Acknowledgment Form (page 8 of the application)

📞 Questions?

Call your regional intake line (shown above) with any questions before submitting. You can also visit mass.gov/dds for more information.

Applicant Information

Guardianship

Current Situation

Type of Application

Parent or Immediate Contact

Authorized Contact

Authorization for Release of Information

Additional Recipients & Authorization Details

Authorization & Signature

Your PDF is Ready!

📍 Determining your region…

📮 Mail or Fax Your Application

📞 Questions?