When requesting an IBL, the provider must complete an Individual Consent to HCBS Limitation(s) form, APD 0556 (also referred to as the 556, or the IBL form). Every individual is unique. As we work through situations where an IBL may be appropriate, we need to honor the individual’s preferences and decisions, making

When requesting an IBL, providers should complete this form (CH-003-IBL), provide all the documentation outlined to support the implementation of an IBL, and submit to Comagine Health. Please complete a separate CH-003 form for each IBL requested.

For definitions and a full explanation of the Home and Community-Based Services (HCBS) Individually-Based Limitation (IBL) process, refer to Oregon Administrative Rule chapter 411, division 4. Additional tools and information can be found on the Oregon Department of Human Services, HCBS website, under the APD program, at:

This form is to be completed when there is an Individually-Based Limitation(s) to the HCBS rule requirements proposed in a provider-owned, controlled or operated residential setting. Select the appropriate limitation(s) from the list below by providing the requested start and end dates for the limitation(s). These dates cannot exceed one (1) year.

2017年8月1日 · Facility records, resident records, medication administration records and more.

Please submit form CH-003 to request an individually-based limitation (IBL). Download Download CH-003 (PDF)

Title: Individual Consent to HCBS Limitation(s) Author: Oregon Department of Human Services Subject: APD 0556 \(07/2019\) Created Date: 12/3/2020 1:59:19 PM

The form identifies and documents, at minimum, all of the following requirements: (a) The specific and individualized assessed need justifying the individually-based limitation. (b) The positive interventions and supports used prior to any individually-based limitation. (c) Less intrusive methods that have been tried but did not work.

The complete Person Centered Information form(s) is filed with the ISP at the CDDP or Brokerage. Family members, as directed by the person, are encouraged to contribute information to this form.

Home and community-based services (HCBS) provide opportunities for Medicaid beneficiaries to receive services in their own homes or communities rather than institutions or other isolated settings. These programs serve people with intellectual or developmental disabilities, physical disabilities and/or mental illnesses.