Forms published to eDocs (October 2019)

Minnesota Department of Human Services sent this bulletin at 10/31/2019 05:00 PM CDT
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Forms published to eDocs

October 2019
eDocs

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-2402-ENG Change Report Form

DHS-2414-ENG Notice of Late or Incomplete Household Report Form, Health Care Renewal Form or Combined Six-Month Report or Recertification

DHS-2776A-ENG Computation of Supplemental Nutrition Assistance Program Overpayment Worksheet

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

DHS-3271-ENG Minnesota Health Care Programs Request for Information

DHS-3274-ENG DHS Request for Approval to Incur Special Expenses Form

DHS-3335A-ENG Fraud Prevention Investigation Referral

DHS-3340-ENG Asset Assessment for Medical Assistance for Long-Term Care Services (MA-LTC)

DHS-3427-ENG LTC Screening Document - AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO

DHS-3428-ENG Minnesota Long Term Care Consultation Services Assessment Form

DHS-3428A-ENG Minnesota Long Term Care Consultation Services Assessment Form: SW Section

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-3755C-ENG Variance request and approval - Child Foster Care 

DHS-3755D-ENG Maximum Capacity or Ratio Variance Request Form - Child Foster Care

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

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

DHS-3876-ENG MHCP Application for Certain Populations

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

DHS-4016A-ENG MHCP Organization - Provider Enrollment Application

DHS-4087-ENG Provider Setup Form

DHS-4469A-ENG Individual Support Worker Enrollment Application (CDCS and CSG)

DHS-4611B-ENG Minnesota Health Care Programs Provider Agreement Volunteer Dentists

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

DHS-5504B-ENG Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers)

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

DHS-6355-ENG DHS Foster Care Candidacy Statistical Report

DHS-6428-ENG MHCP Synagis Authorization Form

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

DHS-6696D-ENG MNsure Appendix A - Health Coverage from Jobs

DHS-6741-ENG MNsure Application for Health Coverage

DHS-6790G-ENG Rate Management Worksheet - Customized Living Services and 24-Hour Customized Living Services

DHS-6790M-ENG RMS Worksheet – Day and Employment Services

DHS-7121-ENG MHCP Immunization Delivery for Dentists Applicant Assurance Statement

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

DHS-7776-ENG Admission and Arrangements - Family Child Care

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

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

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

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

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

 

The following form(s) were made obsolete:

DHS-4043-ENG Enrollment Application for Nursing Facility or ICF/DD

DHS-4215-ENG IEP Provider Enrollment Application

DHS-6790A-ENG RMS Worksheets - Day 15 Minute

DHS-6790B-ENG RMS Worksheets - Adult Day Daily

DHS-6790E-ENG RMS Worksheets - Prevocational Services/Structured Day Program - Daily

DHS-6790F-ENG RMS Worksheets - Prevocational Service Hourly

DHS-4982H-ENG Children's Mental Health - CTSS School Addendum

DHS-4982I-ENG Children's Mental Health - CTSS School Notification of Change

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

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