Forms published to eDocs (March 2019)

Minnesota Department of Human Services logo

Forms published to eDocs

March 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-2708-ENG Community Minnesota Supplemental Aid Budget Worksheet

DHS-2982-ENG County Parental Fee Referral to DHS

DHS-3372-ENG Requirements for services submission checklist

DHS-3491-ENG Consolidated Chemical Dependency Treatment Fund (CCDTF) Provider Assurance Statement

DHS-3954-ENG MHCP Retroactive Medical Assistance (MA) Notice

DHS-4296-ENG General Consent/Authorization for Release of Information

DHS-4734-ENG FQHC/RHC PPS Caseload Survey Questionnaire

DHS-4934-ENG Notice of Estate Claim for Medical Assistance

DHS-6887-ENG Interpreter Website consent form

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

DHS-7667B-ENG Assertive Community Treatment (ACT) Recertification Application


The following form(s) were made obsolete:

DHS-4933-ENG - Application for a Waiver of Claim

DHS-4982-ENG - Children's Mental Health - CTSS School Primary Certification Application - Part 1

DHS-4988-ENG - Children's Mental Health - CTSS Addendum

DHS-4988A-ENG - Children's Mental Health - CTSS Notification of Change Form

DHS-5036A-ENG - Annuity Beneficiary Designation Form - Annuity Owner is the Spouse of Person Seeking Payment of Long Term Care Services

DHS-6351-ENG - Verification of Subsidized Housing Application

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