Disability Services Division eList

TO: Lead agencies and interested stakeholders
FROM:  DHS Aging and Adult Services and Disability Services divisions
EFFECTIVE: Immediately
PURPOSE: To inform lead agencies about new and updated long-term services and supports forms 
CONTACT: DSD.ResponseCenter@state.mn.us

New and revised long-term services and supports forms

In order to assist with support planning activities, DHS has revised and created new long-term services and supports forms.

DHS held a May 19, 2016, webinar to provide training and answer questions on these new forms. See the Long-Term Services & Supports (LTSS) Forms webinar handout (PDF) for more information.

Note: The Disability Services Division Training Archive provides presentation handouts and playback instructions on all trainings.

eDocs to use with MnCHOICES assessments/reassessments

DHS recently updated or added the following forms:

UPDATE: MnCHOICES Community Support Plan with Coordinated Services and Supports Plan Form, DHS-6791B-ENG (PDF)

Certified assessors use this form to develop a Community Support Plan (CSP) following every MnCHOICES assessment. Typically case managers use this form to develop a Coordinated Services and Supports Plan (CSSP) for people who receive publicly funded services. If case management services are not provided (such as with PCA services), a certified assessor develops the CSSP.  Please note that the CSP no longer requires a signature. 

For instructions on how to complete 6791B, see the Instructions for the Community Support Plan with Coordinated Services and Supports Plan DHS-6791C. It also provides details about recent changes made to the form.

NEW: Coordinated Services and Supports Plan Signature Sheet, DHS-6791D (PDF)

County/tribe certified assessors and case managers use this form when they meet with the person to discuss services and develop the CSSP (using the MnCHOICES CSP/CSSP form, DHS-6791B mentioned above). 

This signature sheet captures the person’s participation and verbal agreement in creating his or her CSSP. The signature of the person on this form meets the requirements for the CSSP signature. The person can choose not to sign this form before he/she reviews the completed CSSP.

UPDATE: Long-Term Services and Supports Assessment and Program Information and Signature Sheet, DHS-2727(PDF)

County/tribe certified assessors and/or case managers use this form at each long-term services and supports assessment and reassessment. It helps to inform the applicant/recipient of his/her rights and responsibilities as he/she participates in the assessment and support planning process.

This form formerly was called the "Application for Title XIX Home and Community-Based Waiver Services and Alternative Care (135-Day Eligibility) Program Information and Signature Sheet form."

DHS updated the form to help the certified assessor/case manager explain and discuss recipient rights and responsibilities with the person. This process supports informed choice in the assessment and support planning process.

UPDATE: Your Appeal Rights, DHS-1941 (PDF)

This brochure informs applicants and recipients of all public assistance programs of their right to appeal. It also provides information about how they can get help if they appeal.

Revisions include:

• Replaced "food stamps" reference with "SNAP" in the "reasons for appeal" section
• Added information about having "the right to a hearing where you can see the human service judge in certain circumstances" in the "hearings” section.
• The "who can help" section heading replaced "lawyer or friend can speak for you"
• Added information about requesting a hearing online in the "how to appeal" section.

Obsolete eDocs

Long-Term Care Consultation (LTCC) cost report for face-to-face assessments of persons under 65 years, DHS-5150

DHS deleted this form. The 2013 changes in payment methodology make it unnecessary.