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Eligibility Determination Application

General Applicant Info
Primary contact info
other service system info
If yes, which waiver?
medical/psychological info
Communication style(s) - mark all that apply
current living situation
Living Situation
Legal status

Over 18 years old

Under 18 years old


BLDC CDDO requests that you provide the following information, if applicable, when you submit you application. Please check the documentation you have enclosed with the application. Failure to do so may result in a delay of a determination being made. 

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My signature below verifies that I have read the information that the CDDO has provided, not only in this application, but also the various handouts and brochures I received.  I have been provided the opportunity to contact the CDDO for more information or clarification regarding Intellectual/Developmental Disability (I/DD) Waiver services.   
I understand that if I fail to provide the CDDO with disability-related diagnosis/medical documentation needed for eligibility determination purposes, case closure will result.  Closed files may be reopened at any time upon request. The answers I have provided on this application are true to the best of my knowledge and ability.   

  • Parent/guardian signature is required if applicant is not age 18

  • Individual’s signature is required if applicant is age 18+ (legal guardian may sign on behalf of applicant)

Thank you for submitting your Eligibility Determination Application!

Big Lakes Developmental Center, Inc. CDDO will not reimburse individuals, families, and/or agencies for psychological evaluation fees, postage, faxes, long-distance phone calls, photocopying, travel costs, and/or any other expenses involved with providing the CDDO with eligibility determination documentation. ​

For more information about the Intellectual/Developmental Disabilities (I/DD) Waiver, visit the Kansas Department for Aging and Disability Services’ (KDADS) website:    

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