Forms published to eDocs (December 2018)

Minnesota Department of Human Services sent this bulletin at 01/02/2019 08:15 AM CST
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Forms published to eDocs

December 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-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-2780A-ENG Client Placement Authorization CPA-CCDTF

DHS-3070-ENG Service Agreement

DHS-3324B-ENG Background Studies Supplement to 3324

DHS-3821-ENG ICWA Noncompliance Complaint Form

DHS-4461-ENG Nursing Facility (NF) Communication Form

DHS-4915-ENG Medical Assistance (MA) Payment of Long-Term Care Services

DHS-5678-ENG Request for Resubmission Individual PCA Enrollment Application or Agreement

DHS-5716-ENG MHCP Individual PCA Information Change Form

DHS-5820-ENG Disability Waiver Rates System Exception Request

DHS-5820C-ENG Lead agency provider tool for DWRS exceptions (residential)

DHS-5820D-ENG Lead agency provider tool for DWRS exceptions (day and unit)

DHS-6516-ENG MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Technical Change Request

DHS-6683-ENG Essential Community Supports Program (ECS) Financial Eligibility Worksheet for: • Unmarried individuals • Married couples when both are requesting ECS • Married couples – spouse served under AC, EW or in a nursing home

DHS-6683A-ENG Essential Community Supports Program (ECS) Eligibility Worksheet for a Married Individual when only one spouse is requesting services

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

DHS-6762C-ENG Minnesota Adult Protection Structured Decision Making Safety Plan to Address Current Danger Factors

DHS-6826-ENG Essential Community Supports (ECS) Financial Disclosure Form

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

DHS-7192-ENG We Have Denied Your Health Plan Enrollment Request

DHS-7666-ENG Psychiatric Residential Treatment Facility (PRTF) Individual Plan of Care and Authorization

DHS-7754-ENG Substance Use Disorder (SUD) Provider Assurance Statement - Professionals

DHS-7776-ENG Admission and Arrangements - Family Child Care

DHS-7785-ENG Appeals Public Request Form

DHS-7807-ENG Positive Supports Provider Assurance Statement

DHS-7820-ENG Substance Use Disorder (SUD) Provider Assurance Statement - Counties and Tribes

 

The following form(s) were made obsolete:

None

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