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-3067-ENG DD Screening Document

DHS-3132-ENG Request For Administrative Disqualification Hearing

DHS-3132A-ENG CCAP - Request for Provider Administrative Disqualification Hearing

DHS-3335A-ENG Fraud Prevention Investigation Referral

DHS-4186-ENG Justification for Use of Personal Vehicle Versus Rental Vehicle

DHS-4194-ENG CCAP Special Needs Rate Variance Request – Parent and Provider Request

DHS-4195-ENG CCAP Special Needs Rate Variance Request - County Recommendation Form

DHS-4206C-ENG Quarterly Outpatient Problem Gambling Service Report

DHS-4206D-ENG Quarterly Residential Problem Gambling Service Report

DHS-4207-ENG Gambling Service Agreement and Client Data Form

DHS-5107-ENG Administration of the Child Care Assistance Program - 2020-2021 County and Tribal Child Care Fund Plan

DHS-6184-ENG Fraud Application System Environment Data Practices Agreement

DHS-6185-ENG FASE Access Request Form

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

DHS-6633A-ENG CDCS Community Support Plan Addendum with 2019 Budget Increase

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-6929-ENG Death or Serious Injury Report Fax Transmission Cover Sheet

DHS-7418-ENG Host County Notification of Residential Placement Form

DHS-7652B-ENG Self-monitoring checklist for licensed HCBS providers: Admission and service initiation

DHS-7652C-ENG Self-monitoring checklist for licensed HCBS providers: Service delivery and evaluation

DHS-7652K-ENG Self-monitoring checklist for licensed HCBS providers: Staff qualifications, orientation and training

DHS-7823-ENG Authorization to Obtain Financial Information from the Asset Verification System (AVS)

DHS-7867A-ENG Child Care Assistance Program - Monitoring Visit Summary

DHS-7885-ENG Title IV-E Northstar Adoption Assistance Eligibility Status

DHS-7889-ENG Resource Family and Caseworker Visit Discussion Tool

DHS-7890-ENG Partial Hospitalization Program (PHP) Provider Application

DHS-7896-ENG Documentation to Establish Financial Stability – Grants