Forms published to eDocs (September 2019)

Minnesota Department of Human Services logo

Forms published to eDocs

September 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-1958-ENG Full Child Support (IV-D) Services Application and Information on Child Support

DHS-2818-ENG Authorization for Out-of-State Travel

DHS-2825-ENG Notice of Contracted Per Diem Rates

DHS-3131-ENG Notice of Intentional Program Violation – Waiver of ADH

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-3821-ENG ICWA Noncompliance Complaint Form

DHS-4016-ENG MHCP Individual Practitioner - Provider Enrollment Application

DHS-4060-ENG Request to Close Support Case

DHS-4145-ENG County Notice of IMD Status

DHS-4469-ENG Individual Personal Care Assistant (PCA) Enrollment Application

DHS-4689A-ENG Screening Deletion Request

DHS-4813A-ENG Child and Teen Checkups 0 - 1 Month Well Visit

DHS-4813B-ENG Child and Teen Checkups 2-Month Well Visit

DHS-4813C-ENG Child and Teen Checkups 4-Month Well Visit

DHS-4813D-ENG Child and Teen Checkups 6-Month Well Visit

DHS-4813E-ENG Child and Teen Checkups 9-Month Well Visit

DHS-4813F-ENG Child and Teen Checkups 12-Month Well Visit

DHS-4813G-ENG Child and Teen Checkups 15-Month Well Visit

DHS-4813H-ENG Child and Teen Checkups 18-Month Well Visit

DHS-4813I-ENG Child and Teen Checkups 24-Month Well Visit

DHS-4813J-ENG Child and Teen Checkups 30-Month Well Visit

DHS-4813K-ENG Child and Teen Checkups - 3-year well child visit

DHS-4813L-ENG Child and Teen Checkups 4-Year Well Visit

DHS-4813M-ENG Child and Teen Checkups 5-Year Well Visit

DHS-4813N-ENG Child and Teen Checkups 6-Year Well Visit

DHS-4813O-ENG Child and Teen Checkups 7-Year Well Visit

DHS-4813P-ENG Child and Teen Checkups 8-Year Well Visit

DHS-4813Q-ENG Child and Teen Checkups 9-Year Well Visit

DHS-4813R-ENG Child and Teen Checkups 10-Year Well Visit

DHS-4813S-ENG Child and Teen Checkups 11-Year Well Visit

DHS-4813T-ENG Child and Teen Checkups 12-Year Well Visit

DHS-4813U-ENG Child and Teen Checkups 13 and 14-Year Well Visit

DHS-4813V-ENG Child and Teen Checkups 15-Year Well Visit

DHS-4813W-ENG Child and Teen Checkups 16-Year Well Visit

DHS-4813X-ENG Child and Teen Checkups 17-Year Well Visit

DHS-4813Y-ENG Child and Teen Checkups 18-Year Well Visit

DHS-4813Z-ENG Child and Teen Checkups 19 and 20-Year Well Visit

DHS-5274-ENG Minnesota Child Care Assistance Program Redetermination Form

DHS-5836-ENG Annual Review of Ward under Public Guardianship

DHS-5841-ENG Managed Care Organization, County Agency and Tribal Nation Communication Form - Recommendation for State Plan Home Care Services

DHS-6218-ENG Housing Access Coordination Exception Request for people with criminal, subpar credit or eviction history

DHS-6790G-ENG Rate Management Worksheet - Customized Living Services / 24 Hour Customized Living Services / Residential Care Services

DHS-6979-ENG MnCHOICES Help Desk Contact Form

DHS-7108-ENG CMDE Medical Necessity Summary Information

DHS-7108A-ENG EIDBI Comprehensive Multi-Disciplinary Evaluation (CMDE) Medical Necessity Summary Information Signature Form (Addendum A) 

DHS-7109-ENG Individual Treatment Plan (ITP) and Progress Monitoring

DHS-7109A-ENG EIDBI Individual Treatment Plan (ITP) and Progress Monitoring Signature Form (Addendum A)

DHS-7109B-ENG EIDBI: Additional Developmental Goal Domains Worksheet for ITP Form (Addendum B)

DHS-7414C-ENG Emergency Preparedness Plan - Family Child Care

DHS-7823-ENG Authorization to Obtain Financial Information from the Account Validation Service (AVS)

DHS-7883A-ENG You have been placed on the Child Care Assistance Program (CCAP) waiting list

DHS-7883B-ENG Child Care Assistance Program (CCAP) waiting list update

DHS-7883C-ENG Child Care Assistance Program (CCAP) funds available

DHS-7883D-ENG You will be removed from the Child Care Assistance Program (CCAP) waiting list

DHS-7934-ENG Family Child Care Child Enrollment Form

DHS-7952A-ENG Yearly In-Service Training Record - Licensed Child Care Centers

DHS-7953A-ENG Orientation Training Record - Licensed Child Care Centers

DHS-7954A-ENG Risk Reduction Plan

DHS-7964-ENG Variance request Extended Use of Substitute

DHS-7965-ENG Substitute Hours Tracking

DHS-7966-ENG Licensing Requirement Dispute


The following form(s) were made obsolete:

DHS-5329-ENG - Provider Agreement Addendum - Pharmacy Unit Dose Dispensing

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