Forms published to eDocs (February 2019)

Minnesota Department of Human Services sent this bulletin at 03/01/2019 07:00 AM CST

Forms published to eDocs

February 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-2116-ENG Notice to Apply for Other Maintenance Benefits

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

DHS-3767D-ENG Determination of Cost Effectiveness

DHS-3813-ENG User Agreement for MEC² PRO Electronic Billing

DHS-4935-ENG Determination of Your Request for an Undue Hardship Waiver

DHS-5893-ENG Transfer on Death Deed Application for a Medical Assistance Clearance Certificate

DHS-5893A-ENG Medical Assistance Clearance Certificate for a Transfer on Death Deed

DHS-6165A-ENG Decree of Descent Application for a Medical Assistance Clearance Certificate

DHS-6165B-ENG Medical Assistance Clearance Certificate for a Decree of Descent

DHS-6475-ENG CCAP Parent Request for In-Home Child Care

DHS-7120B-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Assurance Statement

DHS-7120E-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level II Provider Assurance Statement

DHS-7583-ENG Minnesota Child Care Assistance Programs Death, Serious Injury, Maltreatment Report Form

DHS-7843-ENG Special Needs Trust Reporting

DHS-4935A-ENG - Determination of Waiver Request - Requestor

DHS-4935B-ENG - Determination of Waiver Request - Attorney

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