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Provider Assurance Form

Provider Assurance Form

The following assurances are required from a provider of Adult Day Supports (ADS), Vocational Habilitation (VH), and Intermediate Care Facility (ICF) Day Programs for each facility-based setting where ADS, VH, and ICF Day Programs will resume.

If ADS, VH, or ICF Day Program services are provided in multiple facility-based settings, a separate form must be completed for each setting.

Completed Provider Assurance Forms are to be submitted to the Ohio Department of Developmental Disabilities (DODD) (via email: OSSAS@dodd.ohio.gov) and the appropriate county board(s). DODD and the county board(s) will confirm their receipt of the forms within one business day.

Providers are approved to resume services once their assurance documentation is submitted to DODD and the appropriate county board(s), DODD has conducted a virtual tour, and they have received a confirmation email from both. This process will need to be repeated for each area if the provider wishes to modify their services areas to increase their overall capacity.

For providers who have previously submitted an assurance form and been approved for groups of 10 under the previous Ohio Department of Health order, those services may continue and a new assurance form does not have to be submitted unless the provider is adding areas not previously approved.