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SD Department of Human Services Division of Long Term Services and Supports

3800 Highway 34 , c/o 500 East Capitol Ave., Pierre, SD, 57501, US


HCBS Settings Modification Request

The HCBS Settings Final Rule ensures that all consumers on Medicaid who are residing in HCBS settings have control over their location, living arrangements, privacy, dignity and respect, physical accessibility, autonomy, and community integration.

In rare instances, certain rights may need to be restricted to ensure a consumer's health and safety. Complete this form if a consumer in your setting requires a modification. The form will be reviewed by Long Term Services and Supports' (LTSS) HOPE Waiver Manager and, if appropriate, sent to the consumer's Service Coordinator to complete the modification process.

No Modification may begin until the Service Coordinator has met with the consumer and a signed copy of the Modification form is added to their Individual Support Plan.

Facility Information

Address of Facility

Name of Person Filling out this Form

Consumer Information

Consumer Name

Modification Information

What type of Modification is being requested? (Check all that apply)

Supporting documentation of diagnoses and/or cognitive or physical impairments.

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Supporting documentation of less restrictive options that were tried.

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Without the implementation of the setting modification(s) requested, the health and safety of the consumer is at risk.

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