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SPD Community Health Support Program (CHSP): Forms
  

Community Health Support Program (CHSP) forms for the CHSP RN Provider

 

The following forms are required for use by the CHSP RN Provider to document and communicate client summary information to the case manager. These forms are not intended to meet or replace documentation requirements set forth in Oregon nursing law and professional practice standards.

 

Important message:
RN Provider documentation forms are for use by CHSP RN Providers for their Medicaid clients only! Use of the forms outside of the CHSP is prohibited.


Form number Description  
SDS 0754 SPD Community Health Support Program RN Service Plan PDF
SDS 0752 SPD Community Health Support Program RN Services Summary DOC
SPD Community Health Support Program forms for Case Managers and Service Coordinators
SDS 0753 SPD Community Health Support Program Client Referral for Community RN Health Evaluation and RN Service Plan PDF
SPD Community Health Support Program forms for Prior Authorization of Ongoing CHSP RN Provider Services and Payment Authorization of Client Re-evaluation
SDS 4102 Case Manager Prior Authorization for SPD Contract RN (Monitoring Visit, Delegation/Teaching Non-Family, Teaching Family) PDF
SDS 4103 Case Manager Payment Authorization for SPD Contract RN (Reassessment) PDF
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