Submit your completed application and all required documents to the Desert Regional Center at 5550 W Flamingo, Ste C1, Las Vegas, NV 89103, ATTN: Intake Dept. You may also fax the documents to (702) 486-5855. For any questions or assistance, contact the intake office at 702 486-7850 during office hours, which are Monday through Friday, 8:00 am to 5:00 pm. Ensure the application is fully completed, signed, and all necessary documentation is attached to avoid delays in processing.

Submit the completed application and supporting documents within 60 days of starting the process. Office hours are Monday through Friday, 8:00 am to 5:00 pm.

The purpose of this form is to apply for services provided by the Nevada Regional Center for individuals diagnosed with intellectual or developmental disabilities. The form ensures that all necessary information and documentation are gathered to assess eligibility and provide appropriate support services. Submitting this form is a crucial step in accessing valuable resources and assistance for individuals with special needs.

• 1. Applicant Name: Full legal name of the individual applying for services.
• 2. DOB: Date of birth of the applicant.
• 3. Address: Residential address of the applicant.
• 4. Diagnosis: Details of the applicant's intellectual or developmental disability.
• 5. Social Security No.: Social Security Number of the applicant.
• 6. Medicaid No.: Medicaid Number of the applicant, if applicable.
• 7. Mandatory Identification Documentation: List of required identification documents, such as birth certificate, social security card, and proof of Nevada residency.
• 8. Mandatory Documentation of Developmental Disability: Educational records and assessments needed to support the diagnosis of a developmental disability.

Failing to submit the form can lead to a significant delay or prevention of service eligibility assessment. Ensure timely submission to avoid disruptions in obtaining needed services.

• Delay in Services: Missing documents can delay the eligibility assessment process, affecting timely access to services.
• Application Closure: If required documents are not submitted within 60 days, the application will be closed.
• Loss of Contact: Failure to submit can result in loss of contact with the Regional Center, complicating future attempts to seek services.

• 1. Applying for Services: Use this form to apply for support services from the Nevada Regional Center.
• 2. Assessing Eligibility: Submit this form and required documents to determine eligibility for services.
• 3. Updating Contact Information: If contact details have changed, submit the updated information using this form.