Forms published to eDocs (November 2018)

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Forms published to eDocs

November 2018

eDocs

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-3274-ENG DHS Request for Approval to Incur Special Expenses

DHS-3642-ENG Emergency Medical Assistance - Care Plan Certification Request

DHS-3960-ENG MHCP Request for Information for Past Health Coverage

DHS-4206A-ENG Monthly Outpatient Problem Gambling Service Report

DHS-4206B-ENG Monthly Residential Problem Gambling Service Report

DHS-4461A-ENG Nursing Facility (NF) Liability Summary

DHS-4555-ENG Authorization for Release of Health Care Information

DHS-4571-ENG Interim Assistance Payment Request

DHS-5224-ENG Indian Child Welfare Act/Minnesota Indian Family Preservation Act Caseworker Checklist

DHS-5227A-ENG Minnesota Indian Family Preservation Act Notice to Indian Child's Tribe(s)

DHS-5227B-ENG Indian Child Welfare Act/Minnesota Indian Family Preservation Act Genogram (Tribal lineage)

DHS-5227C-ENG ICWA Notice of Child Placement Proceeding

DHS-5227D-ENG Supplemental ICWA Notice of Child Placement Proceeding

DHS-5427-ENG Non-Emergency Medical Transportation (NEMT) Services Trip Sheet

DHS-5588-ENG Child Care Assistance Notice of Decision - Denial

DHS-5588A-ENG Child Care Assistance Notice of Decision - Termination

DHS-5665-ENG Child Care Assistance Program - Direct Service Expenditure Adjustment Form

DHS-5820-ENG Disability Waiver Rates System Exception Request

DHS-6428-ENG MHCP Synagis Authorization Form

DHS-6633A-ENG CDCS Community Support Plan Addendum with 2019 EW and AC Budget Increase

DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs

DHS-6696D-ENG MNsure Appendix A - Health Coverage from Jobs

DHS-6741-ENG MNsure Application for Health Coverage

DHS-6749A-ENG GA or MSA Notice of Drug Felon Match

DHS-6930-ENG Supplemental Nutrition Assistance Program Employment and Training Program (E&T)- Notice to Attend Orientation

DHS-7002-ENG Financial Management Services (FMS) – Provider Agreement Addendum for CDCS and CSG Services

DHS-7120E-ENG EIDBI Assurance Statement for Level II Providers

DHS-7181-ENG Adult Rehabilitative Mental Health Services (ARMHS) Provider Application

DHS-7181A-ENG Mental Health Adult Rehabilitative Mental Health Services (ARMHS) Provider Certification Requirements

DHS-7181B-ENG Adult Rehabilitative Mental Health Services (ARMHS) Recertification Application

DHS-7686-ENG Financial Management Services (FMS) Organization Surety Bond

DHS-7781-ENG Human Services Performance Council Application

DHS-7786-ENG Request for fire inspection or reinspection

DHS-7810-ENG General County Request for Emergency Crisis Services Capacity Variance

DHS-7811-ENG Initial County Request for Emergency Crisis Services Capacity Variance

DHS-7812-ENG General License Holder Request for Emergency Crisis Services Capacity Variance

DHS-7813-ENG Initial License Holder Request for Emergency Crisis Services Capacity Variance

 

The following form(s) were made obsolete:

DHS-3909B-ENG (Institutional Review Board (IRB) Notice of Privacy Practices)

DHS-6244-ENG (Request for determination of coverage for school-based services)

DHS-6247-ENG (Abilify Quantity Limit Review and Criteria Sheet)

DHS-6469-ENG (Evidence-based Perinatal Program Data Collection Form – Births)

DHS-6740-ENG/HMN/RUS/SOM/SPA/VIE (MNsure Small Business Health Options Program (SHOP) Health Coverage Application for Employers)

DHS-6740A-HMN/RUS/SOM/SPA/VIE (MNsure Small Business Health Options Program (SHOP) application for Employees)


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