Forms published to eDocs (August 2021)

Minnesota Department of Human Services logo

Forms published to eDocs

August 2021

eDocs

 

DHS-1958-HMN Application for child support services (Paper) 

DHS-1958-HMN Application for child support services (Online)

DHS-1958-RUS Application for child support services (Paper

DHS-1958-RUS Application for child support services (Online)

DHS-1958-SOM Application for child support services (Paper)

DHS-1958-SOM Application for child support services (Online)

DHS-1958-SPA Application for child support services (Paper) 

DHS-1958-SPA Application for child support services (Online) 

DHS-1958-VIE Application for child support services (Paper)

DHS-1958-VIE Application for child support services (Online

DHS-3491-ENG Behavioral Health Fund (BHF) Provider Assurance Statement

DHS-3725-ENG EFT Supplier ID Notification

DHS-3747-ENG Individualized Home Supports Provider Assurance Statement

DHS-3872-ENG Advanced Diagnostic Imaging Assurance Statement

DHS-3873-ENG Supported Employment Service Providers - Moving Home Minnesota - Provider Assurance Statement

DHS-3887-ENG Hospital Presumptive Eligibility Provider Assurance Statement

DHS-3898-ENG Hospital In-Reach Service Coordination (IRSC) Provider Assurance Statement

DHS-3932-ENG Limited General Dentist Assurance Statement

DHS-4773-ENG Minnesota Family Planning Program (MFPP) Application Packet

DHS-5078-ENG Limiting MHCP Caseload (Rule 101) Provider Assurance Statement (Dental)

DHS-5078A-ENG Limiting MHCP Caseload (Rule 101) Provider Assurance Statement

DHS-5274-ENG Minnesota Child Care Assistance Program Redetermination Form

DHS-5308-ENG Community Health Worker (CHW) Provider Assurance Statement

DHS-5504-ENG HCBS Waivers/AC Reimbursement Request for Unforeseen Circumstances

DHS-5671-ENG Child Care Basic Sliding Fee Monthly Waiting List

DHS-5732-ENG Community Health Clinic Provider Assurance Statement

DHS-5748-ENG Community Mental Health Center Assurance Statement

DHS-5857-ENG Tribal Provider Assurance Statement for Assessments for Personal Care Assistance (PCA) or Community First Services and Supports (CFSS)

DHS-6005-ENG PCA Agency Provider Assurance Statement

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

DHS-6025-ENG Collaborative Practice Dental Hygienist Assurance Statement

DHS-6095-ENG Certified Mental Health Rehabilitation Professional Assurance Statement

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

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

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

DHS-6189J-ENG Home Delivered Meals Provider Assurance Statement

DHS-6189K-ENG Homemaker Provider Assurance Statement

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

DHS-6189T-ENG Specialized Equipment and Supplies Provider Assurance Statement

DHS-6189W-ENG Transitional Services Provider Assurance Statement

DHS-6189X-ENG Customized Living 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-6189AA-ENG Adult Day Services Provider Assurance Statement

DHS-6189CC-ENG Personal Emergency Response System Provider Assurance Statement

DHS-6260C-ENG MHCP Medical Assistance for Employed Persons with Disabilities (MA-EPD) Approval Notice for American Indians

DHS-6330-ENG Qualified Mental Health Professional Clinical Supervision Assurance Statement

DHS-6381-ENG Residential or Inpatient Behavioral Health Fund (BHF) Service Request

DHS-6382-ENG Outpatient Behavioral Health Fund (BHF) Service Request

DHS-6791A-ENG MnCHOICES Community Support Plan Worksheet

DHS-6806-ENG Telemedicine Provider Assurance Statement

DHS-6808-ENG Overnight Assistance Provider Assurance Statement

DHS-6939-ENG MA-EPD Good Cause Application

DHS-7099-ENG Home Care Nurse - Individual LPN or RN Provider Assurance Statement

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

DHS-7109A-ENG EIDBI transition and/or discharge summary

DHS-7120A-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Comprehensive Multi-Disciplinary Evaluation (CMDE) Provider Assurance Statement

DHS-7120B-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Agency Assurance Statement

DHS-7120C-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Qualified Supervising Professionals (QSP) Assurance Statement

DHS-7120D-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level I Provider Assurance Statement

DHS-7120E-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level II Provider Assurance Statement

DHS-7120F-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Level III Provider Assurance Statement

DHS-7121-ENG Immunization Delivery for Dentists Provider Assurance Statement

DHS-7122-ORM Professional Statement of Need

DHS-7124-ENG Child Foster Care or Adoption Background Study

DHS-7227-ENG Pharmacy Retrospective Billing Assurance Statement

DHS-7307-ENG Housing Focused Person-Centered Plan

DHS-7307A-ENG Housing Focused Person-Centered Plan + HCBS Rights Modification Form

DHS-7323-ENG Customized Living Provider Assurance Statement

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

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

DHS-7666-ENG Psychiatric Residential Treatment Facility (PRTF) Individual Plan of Care and Authorization

DHS-7696-ENG Psychiatric Residential Treatment Facility (PRTF) Eligibility for Admission

DHS-7689-ENG Critical Access Mental Health Provider Assurance Statement

DHS-7695-ENG Psychiatric Residential Treatment Facility (PRTF) Extended Leave Request

DHS-7750-HMN Application to Provide Social Security Advocacy Services

DHS-7750-SOM Application to Provide Social Security Advocacy Services

DHS-7750-SPA Application to Provide Social Security Advocacy Services

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

DHS-7807-ENG Positive Supports Provider Assurance Statement

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

DHS-7846-ENG Extended Inpatient Psychiatric Services Provider Application 

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

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

DHS-7968-ENG Housing Consultation Provider Assurance Statement 

DHS-8069-ENG Problem Gambling Training Scholarship Application

DHS-8097-HMN Qualified Residential Treatment Program (QRTP) Placement Assessment and Recommendation

DHS-8097-RUS Qualified Residential Treatment Program (QRTP) Placement Assessment and Recommendation 

DHS-8097-SOM Qualified Residential Treatment Program (QRTP) Placement Assessment and Recommendation

DHS-8097-SPA Qualified Residential Treatment Program (QRTP) Placement Assessment and Recommendation

DHS-8097-VIE Qualified Residential Treatment Program (QRTP) Placement Assessment and Recommendation

DHS-8116-ENG Customized Living Service Provider – Exempt from Assisted Living Facility Licensure – Assurance Statement 

DHS-8122-ENG Respite Providers with a 245D or 144A License Providing Services in an Unlicensed Setting – Assurance Statement 

DHS-8136-ENG Qualified residential treatment program (QRTP) checklist

DHS-8137-ENG Supervised independent living (SIL) checklist 

DHS-8138-ENG Pregnant and parenting youth (PPY) checklist 

DHS-8139-ENG Sex trafficked, commercially sexually exploited (STY), and/or at risk youth checklist 

DHS-8141-ENG Community First Services and Supports (CFSS) Assurance Statement for Consultation Services Lead Employee

DHS-8142-ENG Opioid Prescribing Quality Improvement Report Form

 

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.