Forms published to eDocs (January 2024)

Minnesota Department of Human Services logo

Forms published to eDocs

January 2024

eDocs logo

DHS-1609-SPA Nonreceipt/Replacement Request 

DHS-1795-ENG SSI Interim Assistance Authorization

DHS-3418-ENG Minnesota Health Care Programs Renewal

DHS-3550-ENG Minnesota Child Care Assistance Program Application

DHS-4016-ENG MHCP Individual Provider Enrollment Application

DHS-4163 - Client responsibilities and rights (HMN | RUS | SOM | SPA | VIE)

DHS-4461-ENG Nursing Facility (NF) Communication Form

DHS-4469-ENG Individual Personal Care Assistant (PCA) Enrollment Application

DHS-4797-ENG Notification of Eligibility for Behavioral Health Home (BHH) Services

DHS-4915-ENG Medical Assistance (MA) Payment of Long-Term Care Services

DHS-5223D - Combined Application - Child Care Addendum (HMN | RUS | SOM | SPA | VIE)

DHS-5274 - Combined Application - Child Care Addendum (HMN | RUS | SOM | SPA | VIE)

DHS-5841-ENG Managed Care Organization, County Agency and Tribal Nation Communication Form - Recommendation for State Plan Home Care Services

DHS-6125B-ENG State Medical Review Team Adult Continuing Disability Review Worksheet

DHS-6126-ENG State Medical Review Team Children's Disability Worksheet

DHS-6126B-ENG State Medical Review Team Children's Continuing Disability Review Worksheet 

DHS-6189H-ENG Family Caregiver Services Provider Assurance Statement

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

DHS-6383-ENG Lead Agency Assurance Statement: HCBS Provider Review and Approval

DHS-6715-ENG Protected Transport - Level-of-Service (LOS) Assessment

DHS-6759I-ENG Moving Home Minnesota (MHM) Informed Consent Form

DHS-6759N-ENG Moving Home Minnesota (MHM) Transition Coordination Services Referral Form

DHS-6806-ENG Telehealth Provider Assurance Statement

DHS-6979-ENG MnCHOICES Help Desk Contact Form

DHS-7020-ENG Responder Information/Declarations Form – Grant RFP

DHS-7122-ENG Professional Statement of Need for Housing Stabilization Services and Minnesota Housing Support

DHS-7359-ENG Renewal Yearly Income Statement 

DHS-7823-ENG Authorization to Obtain Financial Information from the Account Validation Service (AVS)

DHS-7896-ENG Documentation to Establish Financial Stability – Grants

DHS-8018-ENG Housing Stabilization Services – Provider Enrollment Application

DHS-8121-ENG Day Training and Habilitation (ICF/DD) Provider Enrollment Application

DHS-8225-ENG Rate Exception Request: Fee-for-Service Subcontracted Targeted Case Management

DHS-8373-ENG Child Care Center Medication Authorization

DHS-8407-ENG Complaint and Grievance Procedures for Foster Care

DHS-8456 - SNAP Work Rules Screening Questions (HMN | RUS | SOM | SPA | VIE)

DHS-8479A-ENG Psychotropic medication monitoring form: Background information and support team observations

DHS-8479B-ENG Psychotropic medication monitoring form: Effects on quality of life and person-centered summary

DHS-8479C-ENG Psychotropic medication monitoring form: 4+1 questions tool

DHS-8479D-ENG Psychotropic medication monitoring form: What is working and not working tool

DHS-8479E-ENG Psychotropic medication monitoring form: Important to/for tool 

DHS-8479F-ENG Psychotropic medication monitoring form: Relationship chart tool 

DHS-8483-ENG General Request for Reconsideration of a Disqualification

DHS-8511-ENG Information about Joint Bank Accounts

DHS-8513-ENG Recuperative Care Extended Stay Request

DHS-8533-ENG FFPSA Allocation Agency Plan


Form(s) made obsolete:

DHS-7694-ENG - Psychiatric Residential Treatment Facility (PRTF) Notice of Denial

DHS-7697-ENG - Psychiatric Residential Treatment Facility (PRTF) Pending Notice

DHS-7699-ENG - Psychiatric Residential Treatment Facility (PRTF) Notice of Approval


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