Forms published to eDocs (August 2019)

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Forms published to eDocs

August 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-2919-ENG Verification Request Form

DHS-3067-ENG DD Screening Document

DHS-3550-ENG Minnesota Child Care Assistance Program Application

DHS-3610-ENG Children's Therapeutic Services and Supports (CTSS) Primary Certification Application

DHS-3725-ENG EFT Vendor Number Notification

DHS-3767-ENG Request for Group Health Plan Information

DHS-3767A-ENG Request for Employee's Group Health Plan Information

DHS-3767B-ENG Request for Individual Health Plan Information

DHS-3767C-ENG Request for Policyholder's Insurance Information

DHS-3767E-ENG Your Health Insurance Is Cost Effective

DHS-3767F-ENG Your Health Insurance Is Not Cost Effective

DHS-3767G-ENG Application for a Good Cause Waiver

DHS-3767H-ENG Determination for a Good Cause Waiver

DHS-3956-ENG Elderly Waiver Conversion Rate Request

DHS-4049-ENG Provider Enrollment Application for Billing Intermediaries, Clearinghouses and EDI Trading Partners

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

DHS-4461A-ENG Nursing Facility (NF) Liability Summary

DHS-5038-ENG Minnesota Health Care Programs Request to Reopen Medical Assistance (MA)

DHS-5223D-ENG Combined Application - Child Care Addendum

DHS-6887-ENG ASL Interpreter Website Consent Form

DHS-7093A-ENG Request to apply for behavioral health home (BHH) services certification

DHS-7602-ENG Critical Access Dental Payment Program Encounter Data Request

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

DHS-7949-ENG Notice to agency of parent's intent to file a petition to re-establish parental rights

DHS-7952B-ENG Yearly In-Service Training Record

DHS-7953B-ENG Orientation Training Record

DHS-7954B-ENG Risk Reduction Plan - Certified Child Care Centers

DHS-7955-ENG Addendum: Emergency Preparedness Plan


The following form(s) were made obsolete:

DHS-4106B-ENG – Health plan enrollment form for non-disabled people under age 65

DHS-4976-ENG – CTSS Recertification Application (replaced by DHS-3610)

DHS-6389-ENG – Children's Therapeutic Services and Supports School Recertification Application (replaced by DHS-3610)

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