Forms published to eDocs (August 2020)

Minnesota Department of Human Services logo

Forms published to eDocs

August 2020



DHS-4145-ENG County Notice of IMD Status

DHS-4296-ENG General Consent/Authorization for Release of Information

DHS-5682A-ENG Employee Injury/Illness Notification Form

DHS-5682B-ENG Supervisor Notification of Employee Injury/Illness

DHS-5682C-ENG Supervisor Accident/Injury Review

DHS-6021-ENG Request to Close or Develop New Corporate Foster Care (and Community Residential Settings)

DHS-6189AA-ENG Adult Day Services Provider Assurance Statement

DHS-6189B-ENG Alternative Care (AC) Nutrition Services Provider Assurance Statement

DHS-6189D-ENG Assistive Technology Provider Assurance Statement 

DHS-6189F-ENG Chore Services Provider Assurance Statement

DHS-6189G-ENG Environmental Accessibility Provider Assurance Statement

DHS-6189I-ENG Family Training and Counseling Provider Assurance Statement

DHS-6189K-ENG Homemaker Provider Assurance Statement

DHS-6189M-ENG Independent Living Skills Therapy Provider Assurance Statement

DHS-6189W-ENG Transitional Services Provider Assurance Statement

DHS-6189Y-ENG Waiver Transportation Provider Assurance Statement

DHS-6189Z-ENG Provider Not Required to Receive a 245D Program License – Provider Assurance Statement

DHS-6383-ENG Home and Community Based Services (HCBS) Lead Agency Enrollment Request Form

DHS-6638-ENG HCBS Programs Service Request Form

DHS-6791B-ENG MnCHOICES Community Support Plan with Coordinated Services and Supports Form

DHS-7820-ENG Substance Use Disorder (SUD) Provider Assurance Statement - Counties and Tribes

DHS-7886-ENG Crisis Respite Specialized Staff Provider Assurance Statement

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

DHS-8018-ENG Housing Stabilization Services – Provider Enrollment Application


The following form(s) were made obsolete:

DHS-5107A-ENG - Childcare Assistance Program County and Tribal Child Care Plan Amendment

DHS-6176-ENG - Psychiatric Consultation Request Form

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.


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