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DHS-2133-ENG Request for an MHCP Member's Claims Payment History
DHS-2828A-ENG Long-Term Services and Supports Notice of Action (Assessments and Reassessments)
DHS-2828B-ENG Long-Term Services and Supports Notice of Action (Service Plan)
DHS-3203-ENG Referral for an MA Lien or Notice of Potential Claim
DHS-3730-ENG Adult Rehabilitative Mental Health Services (ARMHS) Recertification Recipient Record Review
DHS-3730A-ENG Adult Rehabilitative Mental Health Services (ARMHS) Recertification Personnel Record Review
DHS-3751-ENG Individual Community Living Support (ICLS) - Planning Form
DHS-4159A-ENG Adult Mental Health Rehabilitative Services Authorization Form
DHS-5078-ENG Limiting MHCP Caseload (Rule 101) Provider Assurance Statement
DHS-5190-ENG Minnesota Child Care Assistance Programs Licensed Center Provider Registration and Acknowledgment
DHS-5191-ENG Minnesota Child Care Assistance Programs License Exempt Provider Registration and Acknowledgment
DHS-5192-ENG Minnesota Child Care Assistance Programs Legal Nonlicensed Provider Registration and Acknowledgment
DHS-5504-ENG HCBS Waivers/AC Reimbursement Request for Unforeseen Circumstances
DHS-5880-ENG MHCP Cost of Care for Tuberculosis
DHS-6180-ENG General Counsel's Office Advice Request
DHS-6368-ENG Direct Care and Treatment Organization – Provider Enrollment Application
DHS-6428-ENG MHCP Synagis Authorization Form
DHS-6451-ENG Special Needs BasicCare (SNBC) Choice Form
DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs
DHS-6741-ENG MNsure Application for Health Coverage
DHS-6791B-ENG MnCHOICES Community Support Plan with Coordinated Services and Supports Form
DHS-7108-ENG CMDE Medical Necessity Summary Information
DHS-7109-ENG Individual Treatment Plan (ITP) and Progress Monitoring
DHS-7583-ENG Minnesota Child Care Assistance Programs Death, Serious Injury, Maltreatment Report Form
DHS-7602-ENG Critical Access Dental Payment Program Encounter Data Request
DHS-7611A-ENG Person's evaluation of his or her coordinated service and supports plan (CSSP) – (offline version)
DHS-7611B-ENG Person’s evaluation of his or her service provider for day services (offline version)
DHS-7611C-ENG Person’s evaluation of his or her service provider for non-day or non-residential services (offline version)
DHS-7611D-ENG Person’s evaluation of his or her service provider for residential services (offline version)
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