|
DHS-1844-ENG (PDF) Medical Expenses Request
DHS-2243-ENG MHCP Authorization for Release of Information About Assets
DHS-2883-ENG Request for verification of school attendance/progress
DHS-3443-ENG (PDF) Individual Discharge Information Sheet
DHS-3525B-ENG (PDF) Temporary Medical Assistance Authorization
DHS-3531-ENG (PDF) Application for Medical Assistance for Long-Term-Care Services (MA-LTC) [ SPA (PDF) ]
DHS-3547-ENG (PDF) Medical Assistance for Employed Persons with Disabilities (MA-EPD) Initial Premium Notice
[ HMN (PDF) | RUS (PDF) | SOM (PDF) | SPA (PDF) | VIE (PDF) ]
DHS-3727-ENG (PDF) Combined Annual Renewal For Certain Populations
DHS-3813-ENG (PDF) User Agreement for MEC² PRO Electronic Billing
DHS-3883-ENG (PDF) SMRT Education and Work History
DHS-4106C-ENG Health plan enrollment form for people 65 years old or older
DHS-4296-ENG (PDF) Opioid Treatment Program Central Registry, General Consent/Authorization for Release of Information
DHS-4461-ENG Nursing Facility (NF) Communication Form
DHS-4719A-ENG Guidelines for Developing Policies and Procedures for Certified Centers
DHS-4794: Child Care Assistance Program (CCAP) – Change Report Form
[ HMN (PDF) | RUS (PDF) | SOM (PDF) | SPA (PDF) | VIE (PDF) ]
DHS-5165-ENG Child Care Assistance Notice of Deduction for Child Support Obligation
DHS-5367: Minnesota Child Care Assistance Programs - Parent Acknowledgment When Choosing a Legal Nonlicensed Provider
[ HMN (PDF) | SOM (PDF) | SPA (PDF) ]
DHS-5588-ENG Child Care Assistance Notice of Decision - Denial
DHS-5588A-ENG Child Care Assistance Notice of Decision - Termination
DHS-5841-ENG Lead Agency Communication Form: Recommendation for State Plan Home Care Services
DHS-6189M-ENG (PDF) Independent Living Skills Therapy Provider Assurance Statement
DHS-6260C-ENG (PDF) MHCP Medical Assistance for Employed Persons with Disabilities (MA-EPD) Approval Notice for American Indians
DHS-6382-ENG (PDF) Substance Use Disorder (SUD) Services and Level of Care Assurance Statement
DHS-6451-ENG Special Needs BasicCare (SNBC) Choice Form
DHS-6638-ENG (PDF) Home and Community-Based Services (HCBS) Programs Service Request
DHS-6696-ENG (PDF) MNsure Application for Health Coverage and Help Paying Costs [ HMN (PDF) | SPA (PDF) ]
DHS-6696D-ENG (PDF) Appendix A - Health Coverage from Jobs
[ HMN (PDF) | SPA (PDF) ]
DHS-6893M-ENG CFSS Assessment for 45-Day Temporary Increase
DHS-6893W-ENG Lead Agency Addendum to CFSS Individual Service Delivery Plan (DHS-6893P)
DHS-7954B-ENG Risk Reduction Plan for Certified Child Care Centers
DHS-8122-ENG (PDF) Respite Providers with a 245D or 144A License Providing Services in an Unlicensed Setting – Assurance Statement
DHS-8431-ENG (PDF) Request for Information to Determine Eligibility for Certain Populations
DHS-8432-ENG (PDF) Request for Information to Determine Eligibility for Families with Children and Adults
DHS-8511-ENG (PDF) Information about Joint Bank Accounts
DHS-8671-ENG Child Care Assistance Program (CCAP) Provider Forms Submission Site
DHS-8706-ENG (PDF) Vendor's Invoice Stipend
DHS-8747-ENG (PDF) Recuperative Care Provider Pre-Enrollment Risk Assessment
DHS-8770-ENG (PDF) Court Review for Foster Youth Before Age 18
|
