Forms published to eDocs (December 2023)

Minnesota Department of Human Services logo

Forms published to eDocs

December 2023

eDocs logo

DHS-0852-ENG MN Merit System – Report of Personnel Action

DHS-0857-ENG MN Merit System – Probationary Evaluation

DHS-0858-ENG MN Merit System – Separation Rating

DHS-0876-ENG MN Merit System – Position Description

DHS-1609-ENG Nonreceipt/Replacement Request 

DHS-2630-ENG Alternative Care Program Eligibility Worksheet

DHS-2630A-ENG Alternative Care Program Eligibility Worksheet Type A

DHS-3141-ENG Variance Request

DHS-3535-ENG MHCP Individual Provider Profile Change

DHS-3725-ENG EFT Supplier ID Notification

DHS-3751-ENG Individual Community Living Support (ICLS) - Planning Form

DHS-3891A-ENG Request for Early Intensive Developmental and Behavioral Intervention (EIDBI) NETStudy 2.0 Agency ID Number

DHS-4015-ENG Home and Community Based Services (HCBS) – Provider Enrollment Application

DHS-4258B-ENG Minnesota Adoption and Foster Care Individual Fact Sheet

DHS-5181-ENG LTC: Communication of long-term supports and services eligibility form

DHS-5223D-ENG Combined Application - Child Care Addendum

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

DHS-5820C-ENG Lead agency provider tool for DWRS exceptions (residential)

DHS-5820D-ENG Lead agency provider tool for DWRS exceptions (day or unit) 

DHS-5820E-ENG Lead Agency Provider Tool for DWRS Exceptions (Customized Living)

DHS-6683-ENG Essential Community Supports Program (ECS) Eligibility Worksheet

DHS-6683A-ENG Essential Community Supports Program (ECS) Eligibility Worksheet Type A

DHS-6759H-ENG Moving Home Minnesota Communication Form

DHS-7118-ENG Universal Licensing Application

DHS-7120A-ENG Early Intensive Developmental and Behavioral Intervention (EIDBI) Comprehensive Multi-Disciplinary Evaluation (CMDE) Provider 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-7190B-ENG PCA/CFSS Cost Reporting Time Study Worksheet

DHS-7197-ENG Child Care Assistance Program Case Review – Corrective Action Form

DHS-7219-ENG Optional Form for Parent Statement: Infant Less Than Six Months of Age Regularly Rolling Over

DHS-7645B-ENG EIDBI Benefit: Provider agency rights and responsibilities (CMN | HMN | KAR | ORMRUS | SOM | SPA | VIE)

DHS-7683-ENG Accreditation Fee Reimbursement Request

DHS-8059-ENG Waiver Services Remote Support Provider Assurance Statement

DHS-8070L-ENG Great Start Compensation Support Payment Program: Legal Nonlicensed One-Time Payment Application

DHS-8159 Supplemental Nutrition Assistance Program (SNAP) Work Rules Notice (HMN | RUS | SOM | SPA | VIE)

DHS-8313-ENG Child Foster Care Home Safety Checklist

DHS-8529-ENG Cradleboard Variance Request Form

DHS-8531-ENG Helmet Approval for Sleeping Infant

DHS-8536-ENG Parent Cradleboard Request and Monthly Cradleboard Check Form


Form(s) made obsolete:

DHS-3956A-ENG - Elderly Waiver CDCS Conversion Rate Request

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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