Forms published to eDocs (November 2018)

Minnesota Department of Human Services sent this bulletin at 11/30/2018 06:00 PM CST
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Forms published to eDocs

November 2018
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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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