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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.

This process only needs to be completed once per setting. 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.

For providers who have maintained services throughout the state of emergency, those services may continue, but the Provider Assurance form must be completed and submitted to DODD and the appropriate county board(s).