THE REQUEST PROCESS
 

 

 

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LISS REQUEST FORM

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We DO NOT process faxed or emailed requests.
Please send information to:
PENN-MAR HUMAN SERVICES/LISS
310 OLD FREELAND ROAD
FREELAND, MD 21053

In an effort to serve as many families as possible, LISS is intended to

be a last resort for funding and other funding sources must be exhausted

prior to the distribution of LISS funds.

LISS funds can assist with future services that have not already

taken place or been purchased. LISS can not reimburse or pay for

services already occurred.

LISS is not designed to be an emergency resource.

LISS funds are available through the contracted agencies on a first-

come, first served basis. There is no guarantee that funding requests will

be approved.

Anyone can make a referral for LISS services. It is suggested that if you have a case manager/resource/service coordinator that they are contacted so they can assist you through the process.

Once the LISS provider receives the application you will have 10 business days to submit any other items that are required.


Click here for an example of a completed request form.

Click here for a blank request form


What other items should accompany my request?

  • Copy of the individual’s Social Security card

  • Invoice(s) for service(s) being requested

  • Proof of address (State ID or Driver’s License)

  • Proof of Disability

  • Copy of Individual’s Medical Assistance card or proof of Medical Assistance Application (for individuals 18 and older)

  • Original Application with signature (must be mailed)

Depending on the service(s) being requested or the information that

DDA may be missing, more information may be requested by the LISS provider.

Penn-Mar requires that anyone paid for services complete a W-9. 

Click here for a blank W-9

Special Considerations:

Respite Requests

  • On your request form, please indicate the number of days and the daily rate for the respite you are requesting.

  • Respite providers will need to complete an Independent Contractor Agreement, a W-9, and submit proof of their age and address.

  • The Respite provider must be age 18 or older.

Click here for an Independent Contractor Agreement

Medical, Therapeutic, or Disability related requests

  • Please attach an original physician/professional statement recommending the services you are requesting

Click here for Sensory and Therapeutic Letter of Recommendation Tips

Click here for Adaptive Equipment Recommendation Letter Tips

Home Modifications

  • Requests for home modifications must have with them an estimate for the modification on the contractor's letterhead and, if not included on the letterhead, the contractor's MHIC number.

For additional information on requests please refer to the LISS FAQ sheet.