Forms published to eDocs (May 2020)

Minnesota Department of Human Services logo

Forms published to eDocs

May 2020


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-1795-ENG SSI Interim Assistance Authorization

DHS-4074-ENG MA Home Care Technical Change Request

DHS-4795-ENG Minnesota Child Care Assistance Programs Quality Differential Rate Request Form

DHS-4797-ENG Notification of Eligibility for Behavioral Health Home (BHH) Services

DHS-5190-ENG Minnesota Child Care Assistance Programs Licensed Center Provider Registration and Acknowledgment

DHS-5191-ENG Minnesota Child Care Assistance Programs License Exempt Provider Registration and Acknowledgment

DHS-5192-ENG Minnesota Child Care Assistance Programs Legal Nonlicensed Provider Registration and Acknowledgment

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

DHS-6562-ENG Advisory Committee Application Form

DHS-6633B-ENG CDCS Enhanced Budget Request and Community Support Plan Addendum

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

DHS-7195-ENG Licensed Family Child Care Provider Registration and Acknowledgment

DHS-7307-ENG Housing Stabilization Services, Housing Focused Person-Centered Plan

DHS-7309-ENG Patient Referral Arrangement Agreement

DHS-7310-ENG Application for MA Coverage for COVID-19 Testing

DHS-7313-ENG COVID-19 Notification of Operation of Alternative Adult Day Services

DHS-7316-ENG RPO Verbal attestation of eligible status

DHS-7317-ENG RPO Tennessen warning and verbal consent

DHS-7754-ENG Substance Use Disorder (SUD) Provider Assurance Statement - Professionals

DHS-8047-ENG Certification pre-application form


The following form(s) were made obsolete:

DHS-3134A-ENG - Child Care Assistance Program (CCAP) Notice of Program Disqualification for CCAP Providers

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