Forms published to eDocs (December 2018)

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Forms published to eDocs

December 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-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


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