Forms published to eDocs (November 2023)

Minnesota Department of Human Services logo

Forms published to eDocs

November 2023

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DHS-1795A-ENG Interim Assistance Agreement (non-SSI)

DHS-2327-ENG Medical Necessity Statement

DHS-2646-ENG Financial Aid Information

DHS-3741-ENG Your Appeal Rights

DHS-3741A-ENG Minnesota Family Planning Program – Your Appeal Rights

DHS-3956-ENG Elderly Waiver Conversion Rate Request

DHS-4794 – CCAP Change Report Form (HMN | RUS | SOM | SPA | VIE)

DHS-5682A-ENG Employee Injury/Illness Notification Form

DHS-5682B-ENG Supervisor Notification of Employee Injury/Illness

DHS-5682C-ENG Supervisor Review of Employee Injury/Illness 

DHS-6633A-ENG CDCS Community Support Plan Addendum

DHS-6696-ENG MNsure Application for Health Coverage and Help Paying Costs (HMN | RUS | SOM | SPA | VIE)

DHS-6696B-ENG Supplement to the Minnesota Health Care Programs Application for Certain Populations (HMN | RUS | SOM | SPA | VIE)

DHS-6696C-ENG MNsure Application for Health Coverage and Help Paying Costs Signature Pages (HMN | RUS | SOM | SPA | VIE)

DHS-6696D-ENG MNsure Appendix A - Health Coverage from Jobs (HMN | RUS | SOM | SPA | VIE)

DHS-7102-ENG Section 811 Project Based Rent Assistance Pre-Application

DHS-8009-ENG Child Welfare Opiate Allocation - Agency Plan

DHS-8262 – Minnesota Health Care Programs Renewal for Families, Children and Adults (HMN | RUS | SOM | SPA | VIE)

DHS-8355-ENG MCO In-Network Provider Agreement

DHS-8405-ENG Chemical Use Problems Variance Request Form

DHS-8450-ENG Guardian-Conservator Maltreatment and Licensing Agency Checks

DHS-8456-ENG SNAP Work Rules Screening Questions

DHS-8486-ENG Recuperative Care Provider Assurance Statement

DHS-8496-ENG SNAP Employment and Training Eligibility and Enrollment Form


Form(s) made obsolete:

DHS-6759A-ENG - Moving Home Minnesota Approval Notice

DHS-6759B-ENG - Moving Home Minnesota Denial Notice

DHS-6759C-ENG - Moving Home Minnesota Disenrollment Notice

DHS-6759D-ENG - Moving Home Minnesota Reinstatement Notice

DHS-6759E-ENG - Moving Home Minnesota Eligibility Notice

DHS-6759F-ENG - Moving Home Minnesota Suspension Notice

DHS-7016-ENG - State of Minnesota Workforce Certificate Information

DHS-7075-ENG - State of Minnesota – Equal Pay Certificate

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.


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