Supports for Children

Children's Intensive In-Home Services (CIIS)

• Overview
• CIIS Programs and Eligibility
• CIIS Provider Application Processing
• Nursing Delegation
• Forms
• Contacts

Overview

CIIS was developed in response to the needs of families caring for their children with intensive medical or behavioral needs at home. The program was designed to offer flexible, ongoing supports based on the individual needs of the child and family.

Service Coordinators for the program collaborate with individual families statewide to identify and assess needed supports. They then work together to develop plans of support while coordinating with other government and community agencies.

The goal of the program is to offer the most flexible form of supports necessary to enable children to stay in their own home.

CIIS Programs and Eligibility

• Medically Fragile Children's Unit (MFCU)

  Provides support services for children age birth to 18 who have very intense medical needs, are technology dependent and require nursing care.
  
  Eligibility: A clinical criterion as conducted by MFCU nursing staff with input from the families and medical community. DD eligibility is not required. Family income is not a factor for eligibility.

• Intensive Behavior Program

  Provides support services for children up to age 18 who demonstrate intense behaviors that are dangerous to themselves or others. Typically, the entire household must make extreme adaptations to keep everyone safe.
  
  Eligibility: A behavioral criterion as conducted by CIIS staff and reviewed by the CIIS behavioral team. The child must be determined DD eligible by their Community Development Disabilities Program (CDDP). Family income is not a factor for eligibility.

• Medically Involved Program

  Provides support services for children to age 18 who have a medical condition requiring total assistance with all activities of daily living (ADLs). These children are not technology dependent but due to their size and weight require maximum interventions.
  
  Eligibility: A medically involved criterion as conducted by CIIS staff with input from the families and medical community. DD eligibility is not required. Family income is not a factor for eligiblity.

CIIS Provider Application Processing

Individuals and agencies interested in providing in home care or consultation services to children receiving services through CIIS must obtain a provider number through the program. The application process includes:

1. CIIS Provider Application (Word)  (PDF)
2. Criminal History Request - English: (Word) or (PDF); Spanish: (PDF)
3. Consent for Release of Information (Word) or (PDF)
4. Employment Eligibility Verification: I-9 Form 

Mail completed, original applications (items 1-4) to:

If the providers last name begins with the letters A - M:

Nita Cannon

DHS/SPD/CIIS

676 Church Street NE

Second Floor

Salem, OR 97301

If the providers last name begins with the letters N - Z:

Celeste Lopez

600 NW 14th Avenue

Suite 100

Portland, OR 97209

The following forms are recommended for delegation.

You are required to use the delegation timesheet when billing. Contact the service coordinator for more information.

• RN Delegation form (pulse) - (Word) or (pdf)
• RN Delegation form - (Word) or (pdf) 
• Claim for Medically Fragile Child Services Quick Reference (pdf)
• CIIS Consultation Timesheet - (Word) or (pdf)
• Delegation Definitions - (Word) or (pdf)
• Frequently Asked Question for Delegating RNs of CIIS Clients - (Word) or (pdf)
• Letter of Interested Nurses - (Word) or (pdf)
• MD Orders and Plan of Care form - (Word) or (pdf)
• Nursing Assessment form - (Word) or (pdf)
• Available Resourses - (Word) or (pdf)

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Printable Forms

The following forms are posted for your convenience.

• CIIS Medically Involved Children's Program Referral - SDS 4538 (Word) or (pdf)
• CIIS Intensive Behaviors Program Referral - SDS 4539 (Word) or (pdf)
• CIIS Provider timesheet (4 line) (Word)
• CIIS Provider timesheet (6 line) (Word)
• Developmental Disabilities Complaint Form - SDS 0946: English: (Word) or (PDF); Spanish: (Word) or (PDF)
• Notification of Planned Action Form - SDS 0947: SDS 0946: English: (Word) or (PDF); Spanish: (Word) or (PDF)
• Fact Sheet for: Complaints, Medicaid Fair Hearing, Administrative Review - SDS 0948: English: (Word) or (PDF); Spanish: (Word) or (PDF)
• Notification of Rights Form - SDS 0949: English: (Word) or (PDF); Spanish: (Word) or (PDF)

Contacts

• For further information or to make a referral:
  Anyone can refer a child to the program. When appropriate, DD eligibility must be established through the local Community Developmental Disabilities Programs before an evaluation for services can take place.

• For Behavior Program:
  Call 971-673-2995 or send fax to 971-673-2971. Attn: Tara Lindskog

• For Medically Involved Program:
  Call 971-673-2995 or send fax to 971-673-2971, Attn: Tara Lindskog

• For Medically Fragile Children's Unit:
  Call 971-673-3000 or send fax to 971-673-2971, Attn: MFCU intake

• For Provider Application and Processing information:
  Call 503-378-5051

• For families of children with disabilities outside of the Salem area:
  Call 1-888-390-5437

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