Forms published to eDocs (January 2021)

Minnesota Department of Human Services logo

Forms published to eDocs

January 2021



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-3354F-ENG Annual Health Plan Selection Has Ended - managed care letter

DHS-3525B-ENG Temporary Medical Assistance Authorization

DHS-3747-ENG Individualized Home Supports Provider Assurance Statement

DHS-4258A-ENG Minnesota Adoption and Child Foster Care Application

DHS-4786-ENG Sage and Screen Our Circle Screening Programs Medical Assistance (MA) Presumptive Eligibility Agreement

DHS-5887-ENG Additional Square Footage Checklist

DHS-6189C-ENG Adult Companion Services or Individualized Home Supports without Training Provider Assurance Statement

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

DHS-6189X-ENG Customized Living Provider Assurance Statement

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

DHS-6638-ENG HCBS Programs Service Request Form

DHS-6810-ENG Positive Support Transition Plan

DHS-6810A-ENG Positive Support Transition Plan (PSTP) Review

DHS-7109-ENG Individual Treatment Plan (ITP) and Progress Monitoring

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

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

DHS-7340-ENG Officer-Involved Community-Based Care Coordination Assurance Statement

DHS-7618-ENG Home and Community-Based Settings Assurance Statement


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