Forms published to eDocs (January 2020)

Minnesota Department of Human Services sent this bulletin at 02/01/2020 08:00 AM CST
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Forms published to eDocs

January 2020
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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-0029G-ENG MHCP Medical Assistance for Families with Children and Adults (MA-FCA) Income Eligibility

DHS-1795-ENG SSI Interim Assistance Authorization

DHS-2630-ENG Alternative Care Program Eligibility Worksheet for Unmarried Individuals or Married Couples When Both May Choose the Alternative Care Program or a Married Person Whose Spouse is an EW Recipient or is Living in a Nursing Facility

DHS-2630A-ENG Alternative Care Program Eligibility Worksheet for a Married Person who has a Community Spouse

DHS-3418-ENG Minnesota Health Care Programs Renewal

DHS-3727-ENG Combined Annual Renewal For Certain Populations

DHS-3767D-ENG Determination of Cost Effectiveness

DHS-5191A-ENG Certified license exempt center – Short-term alternative location(s)

DHS-5820-ENG Disability Waiver Rates System Exception Request

DHS-5893-ENG Transfer on Death Deed Application for a Medical Assistance Clearance Certificate

DHS-6633D-ENG CDCS Shared Services Agreement

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

DHS-7118-ENG License universal application

DHS-7683-ENG Accreditation Fee Reimbursement Request

DHS-7759E-ENG HCBS Safety Checklist for Out-of-Home Respite Services in an Unlicensed Setting

DHS-7981-ENG Minor Parent Assessment and Service Plan

DHS-7990-ENG Pediatric Symptom Checklist Parent and Youth Screening Tool Q38

 

The following form(s) were made obsolete:

DHS-2776E-ENG - Collectible/Non-Collectible Agency Error Overpayment Worksheet 

DHS-6420-ENG - Application for Certification of Dialectical Behavior Therapy (DBT) Outpatient Providers

DHS-6421-ENG - Application for Recertification of Dialectical Behavior Therapy (DBT) Outpatient Providers

DHS-6790I-ENG - RMS Worksheet - Transportation for Adult Day/Prevocational Services /Structured Day - Daily

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