Use DHS standardized forms for service terminations and suspensions

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Minnesota Health Care Programs (MHCP)
MHCP Providers

Sept. 26, 2025

Use DHS standardized forms for service terminations and suspensions

The 2024 Legislature amended Minnesota Statutes, 245D.10, subdivision 1 to include the requirement:

A license holder must use forms provided by the commissioner to report service suspensions and service terminations under subdivisions 3 and 3a.

The Minnesota Department of Human Services (DHS) has developed standardized forms for reporting service terminations and temporary service suspensions to meet requirements in 2024 legislation. Effective immediately, Home and Community-Based Services licensed 245D providers must use the following forms to report service terminations and suspensions:

Each form includes instructions for how and when providers are required to notify DHS.

Note: Providers must download and open the forms in Adobe Reader or Adobe Acrobat for full functionality. For more information, refer to Frequently asked questions for eDocs.

Contact the Disability Services Division at positivesupports@state.mn.us or the 245D Licensing Help Desk at 651-431-6624.