RESIDENCY DISPUTE DETERMINATION (RDD) REQUEST	
Date of Request
	Date Received	MACSIS UCI No.	
			
Client Name	Date of Enrollment	MACSIS Plan Code Assignment	
			
Current Assigned Board Residency	Other Board Involved	
		
Evidence of Efforts to Resolve Dispute at the Local Level	

	

Evidence of Physical Presence Within the County of Current Assigned Residence	

	

Evidence of Client’s Intent to Stay Within the County of Current Assigned Residence	

	

Evidence of Physical Presence Within the County of Potential Assigned Residence	

	

Evidence of Client’s Intent to Stay Within the County of Potential Assigned Residence	

	

Special Considerations	

	

RDD Panel Determination	

	
	
Residency Assigned to Board	Signature	Date	
			
Copies to:	
		Board Assigned Residence		ODMH/MACSIS RDD Representative	
		Other Board Involved		ODADAS/MACSIS RDD Representative	
		Other, specify:		
DMH-ADM-038 (7/99)