Forms published to eDocs (January 2021) Minnesota Department of Human Services sent this bulletin at 02/01/2021 08:20 AM CST 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 The following form(s) were made obsolete: None 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. If you have questions, contact the eDocs Helpdesk. In order to view PDF forms on eDocs, download the latest FREE version of Adobe Reader.