Forms published to eDocs (December 2019)

Minnesota Department of Human Services sent this bulletin at 12/31/2019 06:00 PM CST
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Forms published to eDocs

December 2019
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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-4681-ENG Summary of Personnel Information

DHS-4915-ENG Medical Assistance (MA) Payment of Long-Term Care Services

DHS-6189D-ENG Assistive Technology Providers Applicant Assurance Statement

DHS-6451-ENG Special Needs BasicCare (SNBC) Choice Form

DHS-6683-ENG Essential Community Supports Program(ECS) Financial Eligibility Worksheet for:Unmarried individuals, Married couples when both are requesting ECS and Married couples-spouse served under AC, EW or in a nursing home

DHS-6683A-ENG Essential Community Supports Program(ECS) Financial Eligibility Worksheet for a Married Individual when only one spouse is requesting services

DHS-6696A-ENG Supplement to MNsure Application for Health Coverage and Help Paying Costs (DHS-6696)

DHS-6751B-ENG EIDBI training materials: Family checklist

DHS-6751F-ENG EIDBI training materials: Case Example Handout Exercises

DHS-6751G-ENG EIDBI training materials: Identifying your culture 

DHS-6751H-ENG EIDBI training materials: Developing an Environment for Effective Service Delivery

DHS-6751I-ENG EIDBI training materials: Effective Evaluation and Treatment Plan Checklist for Providers

DHS-6826-ENG Essential Community Supports Program(ECS) Financial Disclosure Form

DHS-7118-ENG License universal application

DHS-7120A-ENG EIDBI Assurance Statement for Comprehensive Multi-Disciplinary Evaluation (CMDE) Providers

DHS-7120B-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Assurance Statement

DHS-7120C-ENG EIDBI Assurance Statement for Qualified Supervising Professionals (QSP)

DHS-7120D-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level I Provider Assurance Statement

DHS-7120E-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level II Provider Assurance Statement

DHS-7120F-ENG EIDBI Assurance Statement for Level III Providers

DHS-7706-ENG Remote Support - Supported Living Services Provider Applicant Assurance Statement

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

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

DHS-7967-ENG Housing Transition and Housing Sustaining Applicant Assurance Statement

DHS-7968-ENG Housing Consultation Providers Applicant Assurance Statement

DHS-7993-ENG Summary of Information for Substitutes and Unsupervised Volunteers

DHS-7994-ENG Personnel Information Form

DHS-7995-ENG Individual Child Care Program Plan 

DHS-7999-ENG Staffing Patterns

 

The following form(s) were made obsolete:

DHS-4015A-ENG - Provider Agreement Addendum Home and Community Based Services Waiver and AC Programs

DHS-4668-ENG - MHCP Pharmacist Enrollment Application

DHS-7947-ENG - Service Combinations Allowed by Minnesota Health Care Programs (MHCP) for Home and Community-Based Services (HCBS) Waiver 

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