 DHS-0312-SPA Adoption Placement Agreement for a Child Under Guardianship of the Commissioner
DHS-2414-ENG Notice of Late or Incomplete Household Report Form, Health Care Renewal Form, Combined Six-Month Report or Recertification (HMN | RUS | SOM | SPA | VIE)
DHS-2630A-ENG Alternative Care Program Eligibility Worksheet Type A
DHS-3159-ENG Minnesota Voluntary Recognition of Parentage (HMN | RUS | SOM | SPA | VIE)
DHS-3159B-ENG Minnesota Voluntary Recognition of Parentage Revocation Form (HMN | SOM | SPA)
DHS-3531-ENG Application for Medical Assistance for Long-Term-Care Services (MA-LTC)
DHS-3535A-ENG MHCP Organization Provider Profile Change
DHS-3539-ENG Ryan White Annual Certification
DHS-3539B-ENG Ryan White New Applicant Form
DHS-3539F-ENG Ryan White Information Change Form
DHS-3539Z-ENG Ryan White Program Application – Attachments
DHS-3767F-ENG Your Health Insurance Is Not Cost Effective (SOM | SPA)
DHS-3943B-ENG The Child Care Assistance Program (CCAP): What to know about fraud - information for families
DHS-4117-ENG Automatic withdrawal for your support payments
DHS-4277-ENG Long-Term Care Spenddown Refund or Non-collection
DHS-4382-ENG New or Expanding Adult Day Treatment (ADT) Service Application
DHS-4740-ENG Minnesota Family Planning Program (MFPP) Application and Renewal Form
DHS-5239F-ENG Minnesota Family Planning Program Application and Renewal Form – Signature Page (HMN | RUS | SOM | SPA | VIE)
DHS-5274 - Minnesota Child Care Assistance Program Redetermination Form (HMN | RUS | SOM)
DHS-5504C-ENG Exception Request Checklist for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD waivers)
DHS-5716-ENG Individual DSW Information Change Request
DHS-6633-ENG CDCS Budget Exception Request Form
DHS-6633C-ENG Instructions to complete the CDCS Budget Exception Request Form
DHS-6893A-ENG Community First Services and Supports (CFSS) Assessment
DHS-6893B-ENG Referral for Reassessment for PCA/CFSS Services
DHS-6893D-ENG CFSS: Recommendation for Removal from the Budget Model Form
DHS-6893E-ENG Home Care Shared Services Agreement (HCN, PCA or CFSS)
DHS-6893F-ENG PCA Program Responsible Party Form/CFSS Participant Representative Agreement
DHS-6893G-ENG CFSS Program Information and Signature Sheet
DHS-6893P-ENG CFSS Individual Service Delivery Plan
DHS-6893S-ENG CFSS: Consultation Services Session Documentation Form
DHS-6893T-ENG Worker Information form for CFSS budget model
DHS-7108-ENG Comprehensive Multi-Disciplinary Evaluation (CMDE) Medical Necessity Summary Information
DHS-7108S-ENG CMDE Medical Necessity Summary Information Signature Page
DHS-7325-ENG ASAM Certification Checklist
DHS-7641R-ENG Youth Exploitation or Trafficking Safety Plan
DHS-8160-ENG Community First Services and Supports (CFSS) Agency Enrollment Application
DHS-8160A-ENG Community First Services and Supports (CFSS) Agency Agreement Addendum
DHS-8174-ENG Health Care Consumer Support Document Portal – Consumers
DHS-8376-ENG SNAP Homeless Shelter Deduction Worksheet
DHS-8483-ENG General Request for Reconsideration of a Disqualification
MnCHOICES
As part of the process to retire legacy systems for the MnCHOICES revision, after Oct. 1, 2024, lead agencies no longer will be able to use the following forms to complete their work:
- DHS-2727-ENG: LTSS Assessment and Program Information Signature Sheet
- DHS-2727A-ENG: Instructions to complete the LTSS Assessment and Program Information and Signature Sheet
- DHS-3427H-ENG: Health Risk Assessment Screening Document - MSC+, MSHO and SNBC
- DHS-3428-ENG: Minnesota Long Term Care Consultation Services Assessment Form
- DHS-3428A-ENG: Minnesota LTCC Services Assessment Form – SW / PHN Sections
- DHS-3428C-ENG: Minnesota LTCC Services: Supplemental Form for Assessment of Children under 18
- DHS-3428D-ENG: Supplemental Waiver PCA Assessment and Service Plan
- DHS-3428G-ENG: Minnesota Service Change Form for EW and AC Participants
- DHS-3428H-ENG: Health Risk Assessment Form
- DHS-3428Q-ENG: Person's Evaluation of Foster Care, Customized Living or Adult Day Service
- DHS-3614-ENG: CAC Application / Reassessment Support Plan
- DHS-3614A-ENG: Instructions to complete the CAC Application / Reassessment Support Plan
- DHS-4166-ENG: Community Support planning
- DHS-6791D-ENG: Coordinated Services and Supports Plan Signature Page
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