Forms by number

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Forms by number

In this table, frequently used DHS Forms referenced in the manual have been compiled for the manual user by DHS form number. To access all DHS forms, go to the DHS eDocs site.

Documents and written materials in other languages | Forms | A to Z of DSD Forms

DHS-0033 Application to Begin Appeal to State Agency (PDF)

DHS-0035 State Agency Appeals Summary (PDF)
DHS-2638 Day Training and Habilitation Service Agreement (PDF)
DHS-2727 Application for Title XIX HCBS and AC and Program Information and Signature Sheet (PDF)
DHS-2807 Civil Rights Complaint Form: Discrimination in Service Delivery (PDF)
DHS-2828 Notice of Action HCBS Waiver and AC (PDF)
DHS-2868 MHCP Hospice Transaction Form (PDF)
DHS-2981 Medical Assistance (MA) Parental Fee Form (PDF)
DHS-2982 County Parental Fee Referral to DHS (PDF)
DHS-3067 DD Screening Document (PDF)
DHS-3070 Service Agreement (PDF)
DHS-3141 Variance Request (PDF)
DHS-3195 Inter Agency Case Transfer Form (PDF)
DHS-3244P Referral for PCA Services (PDF)
DHS-3361 NF LOC PAS Screening and Community Assessment Instructions (PDF)
DHS-3426 LTCC OBRA Level I Screening for Developmental Disabilities or Mental Illness (PDF)
DHS-3427 LTC Screening - LTCC, CADI, CAC, AC, MSHO, EW, BI, CSG (PDF)

DHS-3427T LTC Screening - Telephone Screening (PDF)

DHS-3428 LTCC Services Assessment Form (PDF)
DHS-3428A LTCC Services Assessment Form – SW Section (PDF)
DHS-3428B AC, EW, CADI & BI Waiver Case Mix Classification Worksheet (PDF)
DHS-3428C LTCC Services Form: Supplemental Form for Assessment of Children under 18 (PDF)
DHS-3428D Supplemental Waiver PCA Assessment and Service Plan (PDF)
DHS-3428E Consent for the Release of Your Name to a Center for Independent Living (CIL) (PDF)
DHS-3471 BI Waiver Assessment and Eligibility Determination (PDF)
DHS-3471A BI Waiver Assessment and Eligibility Determination Instructions (PDF)
DHS-3471B BI Waiver Assessment and Eligibility Determination Checklist (PDF)
DHS-3543 MHCP Request for Payment of Long-Term Care Services (PDF)
DHS-3547 MA-EPD Initial Premium Notice (PDF)
DHS-3614 CAC Application/Reassessment Support Plan (PDF)
DHS-3614A CAC Application/Reassessment Support Plan Instructions (PDF)
DHS-3802A Application for Disability Services Innovative Grants (PDF) and sample contract (PDF)
DHS-3806 Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request (PDF) and instructions (PDF)
DHS-3806A Instructions for MHCP: EIDBI Authorization Request form (PDF)

DHS-3807 EIDBI Advisory Group Agenda Submission Form (PDF)

DHS-3848 DSD Related Conditions Checklist (PDF)
DHS-3848A DSD Related Conditions Checklist - Instructions (PDF)
DHS-4007 County of Financial Responsibility Transfer for FSG (PDF)
DHS-4015 Waiver and Alternative Care - Provider Enrollment Application (PDF)
DHS-4016 MHCP Individual Practitioner Provider Enrollment Application (PDF)
DHS-4016A MHCP Organization - Provider Enrollment Application (PDF)
DHS-4022 MHCP PCPO/PCA Choice Agency Enrollment Application (PDF)
DHS-4022A MHCP Provider Agreement Addendum – PCPO (PDF)
DHS-4022B MHCP Provider Agreement Addendum - PCA Choice Provider (PDF)
DHS-4022C MHCP Qualified Professional (QP) Acknowledgement (PDF)
DHS-4071A MA Home Care Nursing Assessment (PDF)
DHS-4071B MA Home Care Nursing Assessment Instructions (PDF)
DHS-4071C Home Care Nursing Service Decision Tree (PDF)
DHS-4074 MHCP MA Home Care Technical Change Request (PDF)
DHS-4074A MHCP Personal Care Assistance (PCA) Technical Change Request (PDF)
DHS-4109 HCN Hardship Waiver Application (PDF)
DHS-4138 MHCP Provider Agreement (PDF)
DHS-4147A Case Manager’s Guide to Determining ICF/DD LOC for ICF/DD and DD Waiver (PDF)

DHS-4147B Instructions for Case Managers Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services (PDF)

DHS-4166 Community Support Plan (PDF)
DHS-4248 Evaluative Report: Level II PAS for Persons with DD or Related Conditions (PDF)
DHS-4254 Psychotropic Medication Use Checklist for 245B Licensed Programs (PDF)
DHS-4292 PCA Request Fax Form (PDF)
DHS-4293 Maltreatment of Minors and Licensing Violations Report Form (PDF)
DHS-4298 Informed Consent Form for Psychotropic Medication(s) Use (PDF)
DHS-4315 Authorization Request for Mobility Devices (PDF)
DHS-4556 Annual Community Support Plan Rule 185 Compliant (PDF) (Disability Waivers)
DHS-4625 Instructions for Completing and Entering the LTC Screening Document and SA (PDF)
DHS-4669 Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSHO and MSC+ Programs (PDF)
DHS-4677C ICF/DD Local System Needs Plan Amendment (PDF)
DHS-4691 PCA Time and Activity Documentation (PDF)
DHS-4929 Caregiver Living Expenses Worksheet (PDF)
DHS-4960A Day Training and Habilitation (DT&H) Services Determination of Need Application for Expansion (PDF)
DHS-4960B Day Training and Habilitation (DT&H) Services Determination of Need Application for Proprietary Changes, Reductions and Closures (PDF)

DHS-5020 Instructions for Completing and Entering the LTCC Screening Document for SNBC (PDF)

DHS-5148 Behavior Intervention Reporting Form and instructions (PDF)
DHS-5150 LTCC cost report for face-to-face assessments of persons under 65 years (PDF)
DHS-5259 MHCP Disclosure of Ownership and Control Interest of an Entity (PDF)
DHS-5504 Requesting Medicaid Administrative Reimbursement or Reimbursement for Alternative Care form (PDF)
DHS-5504B Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers) (PDF)
DHS-5587A DD Waiver Safety Net Funding Request (Court committed) (PDF)
DHS-5587B DD Waiver Extended Safety Net Funding (Court Committed) (PDF)
DHS-5788 CDCS Alternative Treatment Form for MHCP-Enrolled Physicians (PDF)
DHS-5820 Disability Waiver Rates System Exception Request and instructions (PDF)
DHS-5836 Annual Review of Ward under Public Guardianship
DHS-5887 Disability Services Division Additional Square Footage Checklist (PDF)
DHS-5841 MCO/County/Tribal Agency Communication Form - Recommendation for State Plan Home Care Services
DHS-5856 MHCP Personal Care Assistance (PCA) Program Responsible Party Agreement and Plan (PDF)
DHS-5887 Additional Square Footage Approval Request (PDF)

DHS-5899 MHCP Home Care Shared Services Agreement (HCN or PCA) (PDF)

DHS-6000 MHCP Designation of PCA Billing Person (PDF)
DHS-6005 MHCP PCA Agency Applicant Assurance Statement (PDF)
DHS-6021 Request to develop new Corporate Foster Care (and Community Residential Settings) (PDF)
DHS-6021B Voluntary Closure Application: Corporate Adult Foster Care Planned Closure (PDF)
DHS-6033 MHCP PCA Agency Surety Bond (PDF)
DHS-6041 MHCP PCA Agency Personnel List and Affiliation (PDF)
DHS-6218 MHCP Housing Access Coordination Exception Request for people with criminal, subpar credit or eviction history (PDF)
DHS-6383 HCBS Waiver/AC Programs Lead Agency Provider Enrollment Request Form (PDF)
DHS-6516 MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Technical Change Request and instructions (PDF)
DHS-6516A MHCP: Instructions to complete the EIDBI Technical Change Request Form (DHS-6516A) (PDF)
DHS-6532 CDCS Community Support Plan – Rule 185 Compliant (PDF)
DHS-6566 DSD Application for Emergency Disaster Assistance (PDF)
DHS-6633 Exception to CDCS Budget Methodology (PDF)
DHS-6633A CDCS Community Support Plan Addendum with Provider Rate Increase (PDF)
DHS-6759G Moving Home Minnesota Housing Transitions Worksheet (PDF)

DHS-6759H Moving Home Minnesota Communications Form (PDF)

DHS-6759I Moving Home Minnesota Informed Consent Form (PDF)
DHS-6759J Moving Home Minnesota Transition Planning Tool (PDF)
DHS-6759K Moving Home Minnesota Transition Planning Tool, Part 2: Risk Mitigation (PDF)
DHS-6768 Case manager's cost report for DD full team screenings (PDF)
DHS-6789 List of Monitoring Technology Approval Request Process forms (PDF) [includes 6789A, 6789B and 6789C]
DHS-6790 List of Rates Management System (RMS) Worksheets (PDF)
DHS-6791A MnCHOICES Community Support Plan Worksheet (PDF)
DHS-6791B MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan (PDF)
DHS-6791C Instructions to Complete the MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan (DHS-6791B) (PDF)
DHS-6791D MnCHOICES Coordinated Services and Supports Plan Signature Sheet (PDF)
DHS-6791E MnCHOICES Reassessment Communication Form (PDF) and instructions, 6791F (PDF)
DHS-6810 Positive Support Transition Plan template (PDF) and instructions (PDF)
DHS-6810A Positive Support Transition Plan review (PDF)
DHS-6910 Rates Management (RMS) Residential Shared Staffing Hours Worksheet (PDF)
DHS-6936 Minnesota Employment Communities of Learning (MN ELC) application (PDF)

DHS-6939 MA-EPD Good Cause Application and instructions (PDF)

DHS-6940 MnCHOICES PCA Service Agreement Addendum (PDF)
DHS-6979 MnCHOICES Help Desk Contact Form
DHS-7012 DWRS Rates Mentor Inquiry Form (PDF)
DHS-7108 CMDE Medical Necessity Summary Information
DHS-7108A CMDE Medical Necessity Summary Information Signature Form (Addendum B) (PDF)
DHS-7109 Individual Treatment Plan (ITP) and Progress Monitoring
DHS-7109A ITP and Progress Monitoring Signature Form (Addendum A) (PDF)
DHS-7109B ITP and Progress Monitoring Provider Team Members List (Addendum B) (PDF)
DHS-7109C ITP and Progress Monitoring Week-in-the-Life Schedule (Addendum C) (PDF)
DHS-7109D EIDBI 60-Day Temporary Increase Request for Intervention Services (PDF)
DHS-7109E Instructions to complete 7109D, EIDBI 60-Day Temporary Increase Request for Intervention Services Form (PDF)
DHS-7176 HCBS Provider Attestation
DHS-7185 Case Manager's Recipient Information Form
DHS-7209 DSD DD Waiver Waiting List Category Determination Tool (PDF)
DHS-7279 Olmstead Employment Practice Review Panel Story Template (PDF)

DHS-7418 Host County Notification of Residential Placement Form (PDF)

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