Forms published to eDocs (June 2019)

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Forms published to eDocs

June 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-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


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