[SD Department of Human Services, Division of Long Term Services and Supports] HCBS Modification Form

HCBS Settings Modification Request

The HCBS Settings Final Rule ensures that all HOPE Waiver Medicaid participants 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 participant's health and safety. Complete this form if a HOPE Waiver Medicaid participant 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 participant's Case Management Specialist to complete the modification process.

No Modification may begin until the Case Management Specialist has met with the HOPE Waiver Medicaid Participant and a signed copy of the Modification form is added to their Individual Support Plan.

Facility Information

Name of Facility

Title

Email Address

Phone Number

HOPE Waiver Participant Information

Medicaid Number

Modification Information

Why is the modification being requested? Describe why this level of restriction is necessary and how the modification is consistent with the consumer's needs.

List of diagnoses and/or cognitive or physical impairments that limit the HOPE Waiver participant's ability to safely to complete the activity independently, if applicable.

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

Click Here to Upload

What other less restrictive options were tried to help avoid this modification? (List all alternatives that were tried.)

Supporting documentation of less restrictive options that were tried.

Click Here to Upload

How often will this restriction be reviewed by the facility to determine effectiveness and/or necessity? (Modifications cannot be implemented permanently; they must be reviewed regularly to determine necessity).

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

Yes

Recaptcha Response

Be sure to verify that you are not a robot by using the Captcha tool at the below.

Having reCaptcha issues? Click here to reset the widget.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.