 DHS-2243A-ENG General Authorization for Release of Information
DHS-2630-ENG (PDF) Alternative Care Program Eligibility Worksheet
DHS-2630A-ENG (PDF) Alternative Care Program Eligibility Worksheet Type A
DHS-2776-ENG Computation of MFIP Overpayment Worksheet
DHS-2776A-ENG Computation of Supplemental Nutrition Assistance Program Overpayment Worksheet
DHS-3341: Asset Reduction - Worksheet (HMN | ORM | RUS | SOM | SPA | VIE)
DHS-3550: Minnesota Child Care Assistance Program Application
(HMN | RUS | SOM | SPA | VIE)
DHS-3767D-ENG Determination of Cost Effectiveness
DHS-3799B: Child foster care notice to relatives: Permanency
(HMN | KAR | SOM | SPA)
DHS-4060-ENG (PDF) Request to Close Support Case
DHS-4106C-ENG Health plan enrollment form for people 65 years old or older
DHS-4600-ENG MHCP Notice of Medical Assistance Overpayments
DHS-4801-ENG (PDF) Referral for an Alternative Care Estate Claim
DHS-4915-ENG Medical Assistance (MA) Payment of Long-Term Care Services
DHS-5192F-ENG (PDF) Minnesota Child Care Assistance Program Group Size and Age Limits for Legal Nonlicensed (LNL) Child Care Providers
DHS-5223E-ENG Program Change Request: Minnesota Transition Application Form (HMN | RUS | SOM | SPA | VIE)
DHS-5223S: Combined Application – Household Member Supplement Form
[HMN (PDF) | RUS (PDF) | SOM (PDF) | SPA (PDF) | VIE (PDF)]
DHS-5880-ENG (PDF) MHCP Cost of Care for Tuberculosis
DHS-6125-ENG SMRT Adult Disability Worksheet
DHS-6125B-ENG State Medical Review Team Adult Continuing Disability
Review Worksheet
DHS-6126-ENG State Medical Review Team Children's Disability Worksheet
DHS-6189W-ENG (PDF) Transitional Services Provider Assurance Statement
DHS-6189Y-ENG (PDF) Waiver Transportation Provider Assurance Statement
DHS-6633A-ENG (PDF) CDCS Community Support Plan Addendum
DHS-6633B-ENG CDCS Enhanced Budget Request and Community Support
Plan Addendum
DHS-6873-ENG (PDF) Authorization for Release of Information for the
Successful Life Project
DHS-6893A-ENG Community First Services and Supports (CFSS) Assessment
DHS-6893B-ENG Referral for Reassessment for PCA/CFSS Services
DHS-6893E-ENG (PDF) Home Care Shared Services Agreement
(HCN, PCA or CFSS)
DHS-6893G: CFSS Program Information and Signature Sheet
[HMN (PDF) | KAR (PDF) | RUS (PDF) | SOM (PDF) | SPA (PDF) | VIE (PDF)]
DHS-6893M-ENG CFSS Assessment for 45-Day Temporary Increase
DHS-6893P-ENG CFSS Individual Service Delivery Plan
DHS-6893Q-ENG (PDF) CFSS Individual Service Delivery Plan (Short Version)
DHS-7109A-ENG EIDBI transition and/or discharge summary
DHS-7118-ENG License Application
DHS-7118D-ENG (PDF) Applicant Notarized Agreement, Acknowledgement
and Verification Form
DHS-7807-ENG (PDF) Positive Supports Provider Assurance Statement
DHS-8059-ENG (PDF) Waiver Services Remote Support Provider
Assurance Statement
DHS-8243-ENG (PDF) AC/EW PCA Enhanced Rate Budget Exception Request
DHS-8262-ENG (PDF) Minnesota Health Care Programs Renewal for Families, Children and Adults
DHS-3956 Elderly Waiver Conversion Rate Request
DHS-5090 Application for Rule 36 licensure without a variance
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