Submit Request for Provider

This option is for those individuals/families that choose not to contact providers using the Provider Book or DODD Provider Search Website. Your SSA/EIS will help you put together your Request for Provider (RFP) or you may submit your RFP directly to RCBDD by completing the information below. Once your RFP is submitted, it will be reviewed and may be edited to meet HIPAA privacy requirements and/or people first language.

* must be enrolled in services to submit a request.

Name of person submitting this Request for Provider

This field is required

First Name: * This field is required

Last Name: * This field is required

Email * A valid email address is required

Phone * This field is required

Name of eligible individual

This field is required

First Name: * This field is required

Last Name: * This field is required

Select Service Department * This field is required

Service Type * This field is required

Funding Type * This field is required

Requested day for service?

Description of Service Needed. Please include interests, hobbies, medical, and/or behavioral support. * This field is required

When writing your Request for Provider it is best to be specific about the services and providers you are looking for. Ask yourself... Do I prefer an agency provider or independent provider? What days and times will I need services? Is there any type of specific training I prefer my providers to have? Will my provider need to be able to provide transportation? If you are requesting therapy services, would you like those to be provided in your home or a clinic?

Special instructions (optional, will not be included in the Request for Provider)

Post my Request for Provider on the RCBDD website? * This field is required

Email to Providers? * This field is required

Have Service Providers Contact Me Directly?

If you enter "no" your support administrator will be contacted with the responses.

First Name: * This field is required

Last Name: * This field is required