Forms published to eDocs (August 2021) Minnesota Department of Human Services sent this bulletin at 08/31/2021 05:00 PM CDT Forms published to eDocs August 2021 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. 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