Forms published to eDocs (January 2019)

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Forms published to eDocs

January 2019


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-0029E-ENG Medical Assistance With a Spenddown for Families With Children

DHS-3165A-ENG Supplemental Nutrition Assistance Program Employment and Training (SNAP E&T) Status Update Form

DHS-3610-ENG Children's Therapeutic Services and Supports (CTSS) Primary Certification Application

DHS-3610A-ENG Children's Therapeutic Services and Supports (CTSS) Provider Assurance Statements

DHS-3807A-ENG EIDBI Treatment Modality Submission Form

DHS-4106C-ENG Health plan enrollment form for people 65 years old or older

DHS-4695-ENG MHCP Authorization Form

DHS-4759-ENG Special Needs or Pooled Trust Referral

DHS-5036-ENG Annuity Designation for MA-LTC Applicants

DHS-5037-ENG Notice of Obligation to Issuer of an Annuity

DHS-5682B-ENG Supervisor Injury/Illness Investigation Form

DHS-5682C-ENG Supervisor Accident/Injury Review

DHS-6020-ENG SNAP Employment and Training Plan

DHS-6124-ENG SMRT Authorization to Release Protected Health Information

DHS-6633B-ENG CDCS Enhanced Budget Request and Community Support Plan Addendum

DHS-6759H-ENG Moving Home Minnesota Communication Form

DHS-6810F-ENG Functional Behavior Assessment Quality Checklist

DHS-7020-ENG Responder Information/Declarations Form – Grant RFP

DHS-7109-ENG Individual Treatment Plan (ITP) and Progress Monitoring

DHS-7683-ENG Accreditation Fee Reimbursement Request

DHS-7840-ENG Notice of Intent to bill for Individual Education Plan (IEP) Mental Health Evaluations


The following form(s) were made obsolete:

DHS-5193-ENG  CCAP Authorization for Release of Background Study

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