Forms published to eDocs (July 2018)

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Forms published to eDocs

July 2018


Please note that the following forms may have new web addresses. Web pages or other documents that link to these forms may need to be updated.

DHS-2630-ENG Alternative Care Program Eligibility Worksheet for Unmarried Individuals or Married Couples When Both May Choose the Alternative Care Program or a Married Person Whose Spouse Is an EW Recipient or Is Living in a Nursing Facility

DHS-2630A-ENG Alternative Care Program Eligibility Worksheet for a Married Person who has a Community Spouse

DHS-2981-ENG Medical Assistance Parental Fee Form

DHS-3141-ENG Variance Request

DHS-3159B-ENG Minnesota Voluntary Recognition of Parentage Revocation Form

DHS-3159C-ENG Minnesota Voluntary Recognition of Parentage Spouse's Non-Parentage Statement

DHS-3159E-ENG Minnesota's Spouse's Non-parentage Statement Revocation Form

DHS-3426-ENG OBRA Level I Criteria – Screening for Developmental Disabilities or Mental Illness

DHS-3427-ENG LTC Screening Document - AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO

DHS-3427H-ENG Health Risk Assessment Screening Document - MSC+, MSHO and SNBC

DHS-3427T-ENG LTC Screening Document - Telephone Screening

DHS-3428G-ENG Minnesota Service Change Form for EW and AC Participants

DHS-3428H-ENG Minnesota Health Risk Assessment Form

DHS-3548-ENG Alternative Care Program Client Disclosure Form

DHS-3767D-ENG Determination of Cost Effectiveness

DHS-3767E-ENG Your Health Insurance Is Cost Effective

DHS-4005-ENG TED Application

DHS-4679-ENG Staffing Patterns

DHS-5085-ENG Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP) Services Documentation Log

DHS-5274-ENG Minnesota Child Care Assistance Program Redetermination Form

DHS-6355-ENG DHS Foster Care Candidacy Statistical Report

DHS-6638-ENG HCBS Programs Service Request Form

DHS-7219-ENG Infant Rolling Over Parent Statement for Infant Less Than Six Months Old

DHS-7695-ENG Psychiatric Residential Treatment Facility (PRTF) Extended Leave Request

DHS-7736-ENG Allergy Information Form

DHS-7738-ENG Emergency Phone Numbers

DHS-7741-ENG Liability Insurance Notice to Parents or Guardians

DHS-7743-ENG Monthly Crib Inspection Form

DHS-7744-ENG New Licensing Requirements and Technical Assistance Checklist

DHS-7745-ENG Poisonous Plants Family Child Care

DHS-7746-ENG Prescription and Non-Prescription Medication Administration Permission

DHS-7747-ENG Rule and Statute Summary

DHS-7748-ENG Storm and Fire Drill

DHS-7749A-ENG Swimming Pool Permission

The following form(s) were made obsolete:

DHS-3769B-ENG License Exempt Provider Acknowledgment Form

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