Forms published to eDocs (October 2021)

Minnesota Department of Human Services sent this bulletin at 11/01/2021 09:00 AM CDT

Forms published to eDocs

October 2021

DHS-2780A-ENG Behavioral Health Fund Request (BHF)

DHS-3428M-ENG Mini-Cog© Instructions for Administration and Scoring

DHS-3755C-ENG Variance request and approval - Child Foster Care

DHS-4138-ENG MHCP Provider Agreement

DHS-4561-ENG Rate Adjustment for Scope of Service Change

DHS-5223E-ENG Program Change Request: Minnesota Transition Application Form

DHS-6633A-ENG CDCS Community Support Plan Addendum

DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs

DHS-6696-HMN MNsure Application for Health Coverage and Help Paying Costs - Hmong

DHS-6696-RUS MNsure Application for Health Coverage and Help Paying Costs - Russian

DHS-6696-SOM MNsure Application for Health Coverage and Help Paying Costs - Somali

DHS-6696-SPA MNsure Application for Health Coverage and Help Paying Costs - Spanish

DHS-6696-VIE MNsure Application for Health Coverage and Help Paying Costs - Vietnamese

DHS-6855-ENG Designation of Billing Person for Home and Community-Based Services Waiver or Alternative Care

DHS-7069-ENG Corrective Action Form TANF Audits

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

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

DHS-7316-ENG RPO Verbal attestation of eligible status

DHS-7317-ENG RPO Tennessen warning and verbal consent

None

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