Forms published to eDocs (June 2020)

Minnesota Department of Human Services logo

Forms published to eDocs

June 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-1795A-ENG Interim Assistance Agreement

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-2825-ENG Notice of Contracted Per Diem Rates

DHS-3164-ENG Income withholding-only (Non-IV-D) services application for support order processing

DHS-3539-ENG Ryan White Annual Certification

DHS-3539A-ENG Ryan White Six-Month Recertification

DHS-3539B-ENG Ryan White New Applicant/Information Change

DHS-3539C-ENG Ryan White Verification of Employer Insurance

DHS-3539D-ENG Ryan White Healthcare Provider Request

DHS-3838-ENG Opioid Treatment Program Exemption Request and Record of Justification

DHS-3956-ENG Elderly Waiver Conversion Rate Request 

DHS-6381-ENG Residential or Inpatient Consolidated Chemical Dependency Treatment Fund (CCDTF) Service Change Request

DHS-6633A-ENG CDCS Community Support Plan Addendum with 2020-21 Budget Increase

DHS-6683-ENG Essential Community Supports Program (ECS) Financial Eligibility Worksheet

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

DHS-7122-ENG Professional Statement of Need

DHS-7196-ENG CCAP Provider Registration Change Form

DHS-7313C-ENG Notification of Operation of Day Service Facilities

DHS-7313E-ENG Notification About Resuming Facility Operation for Adult Day Centers

DHS-7323-ENG 1115 Substance Use Disorder (SUD) System Reform Demonstration Project Provider Assurance Statement

DHS-7327-ENG Off Cycle Paid Claims Report Request

DHS-7329-ENG Individual Provider Affiliations

DHS-7335-ENG Adult Foster Care Minimum age variance request for a peacetime emergency 

DHS-7337-ENG Request for public data

DHS-7338-ENG Request for private data about yourself

DHS-7340-ENG Officer Involved Care-Coordination Assurance Statement – Counties

DHS-7846-ENG Extended Inpatient Psychiatric Services Provider Application

DHS-7982-ENG Notice to parents considering voluntary placement of their child co-located with them in a residential substance use disorder treatment program

DHS-7983-ENG Notice to parents or Indian custodians considering voluntary placement of their Indian child co-located with them in a residential substance use disorder program

DHS-7984-ENG Voluntary out-of-home placement agreement for child co-located with parent in residential treatment for substance use disorder

DHS-7985-ENG Voluntary out-of-home placement agreement for a child co-located with parent or Indian custodian in residential treatment for substance use disorder – Indian child


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