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Children's Intensive In-Home Services (CIIS) Provider Tools

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 by completing the Provider Enrollment Packet.

Mail completed, original applications to:
Nita Cannon
DHS/SPD/CIIS
676 Church Street NE
Second Floor
Salem, OR 97301

Nursing Delegation

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)

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: Vanessa Fulton 
  • For Medically Involved Program:
    Call 971-673-2990 or send fax to 971-673-2971, Attn: Sara Bales
  • 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
  • Manager of the Intensive Behavior Program:
    Call 971-673-2976, Pamela Cunningham
  • Manager of the Medically Fragile and Medically Involved Programs:
    Call 971-673-2976, Pamela Cunningham
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