Forms published to eDocs (July 2019)

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Forms published to eDocs

July 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-2977-ENG Important Notice and Parental Fee Worksheet

DHS-3067-ENG DD Screening Document

DHS-3525-ENG Minnesota Health Care Programs Application and Renewal Form Medical Assistance for Women with Breast or Cervical Cancer (MA-BC)

DHS-3531-ENG Application for Medical Assistance for Long-Term-Care Services (MA-LTC) 

DHS-3806-ENG MHCP: Early Intensive Developmental and Behavioral Intervention (EIDBI) Authorization Request

DHS-3869-ENG Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) Surety Bond

DHS-3876-ENG MHCP Application for Certain Populations

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

DHS-4461-ENG Nursing Facility (NF) Communication Form

DHS-5207-ENG County agency address and phone number list

DHS-5259A-ENG Ownership and Control Interest Disclosure Requirement

DHS-6021B-ENG DSD Corporate Adult Foster Care/Community Residential Setting (CRS) Setting Closure Proposal

DHS-6025-ENG Collaborative Practice Dental Hygienist Assurance Statement 

DHS-6633-ENG CDCS Budget Exception Request Form

DHS-6633C-ENG Instructions to complete the CDCS Budget Exception Request Form

DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs

DHS-6791A-ENG MnCHOICES Community Support Plan Worksheet

DHS-7641R-ENG Youth Exploitation or Trafficking Safety Plan

DHS-7921-ENG Professional Development Plan

DHS-7934-ENG Family Child Care Child Enrollment Form


The following form(s) were made obsolete:

DHS-3340E-ENG Asset Assessment Results for Current HCBS Waiver Enrollee

DHS-3340F-ENG Asset Assessment Request for Information for Current HCBS Waiver Enrollee

DHS-6021X-ENG DSD Corporate Adult Foster Care/Community Residential Setting (CRS) Setting Closure Proposal

DHS-7604-ENG Substance Use Disorder Provider Capacity Grant Application

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