Use this form to refer individuals for OBHSP services, including 1915(i), non-1915(i), non-Medicaid, or State Plan Personal Care (SPPC PC 20) services.
Please submit for when an individual moves out of an adult foster care or residential treatment program for behavioral health services.
An individually based limitation (IBL) is based on specific assessed need and only implemented with the informed consent of the individual or, as applicable, the legal representative of the individual, as described in OAR 411-004-0040. The complete rule can be found here. IBLs are only for individuals in home and community-based settings.
This form includes information required for a plan of care for adult foster homes or residential personal care/habilitation services. For an initial referral, this form may accompany Comagine Health Referral Form (CH-001).
Please complete this form to request prior authorization of Psychosocial Rehabilitation Services (outpatient rehabilitation).
To be completed by crisis respite providers. Comagine Health will provide authorizations for Crisis Respite stays for individuals who are in residential and adult foster home settings. Please see form for more information.
Please complete this form to request an authorization for the individuals who will be transitioning to an SRTF. The Independent and Qualified Agent (IQA) will review this request and process it for the individual staying at the identified facility.
Presented by :
Dana Hittle - Oregon Health Authority
Brian Sandoval, Lenora Johnson, and Bennett Garner - Comagine Health