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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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Forms

In this chapter, frequently used DHS Forms referenced in the manual have been compiled for the manual user in one location. Use the DHS eDocs database to search for and download DHS forms, applications and other documents in 10 non - English languages.

PCA forms

PCA forms are now located in the PCA Manual.

Quick links

Billing and MMIS Related Forms | General Forms | Home Care Forms | PCA Forms | Screening Forms | Waiver Provider Enrollment Forms | Waiver Forms | Miscellaneous Forms | A to Z of DSD Forms | Forms by Number

Billing and MMIS Related Forms - Back to top

Day Training and Habilitation Service Agreement DHS-2638 (PDF)
MHCP Acknowledgement by Supervising Qualified Professional DHS-4022C (PDF)

MHCP Individual Practitioner Provider Enrollment Application DHS-4016 (PDF)

MHCP Organization - Provider Enrollment Application DHS-4016A (PDF)

MHCP PCPO Provider Agreement Addendum DHS-4022A (PDF)

MHCP Personal Care Providers Application DHS-4022 (PDF)

Service Agreement DHS-3070 (PDF)

General Forms - Back to top

Appeal to State Agency DHS-0033
County of Financial Responsibility Transfer for FSG DHS-4007 (PDF)

County Parental Fee Referral to DHS DHS-2982

Interagency Case Transfer Form DHS-3195 (PDF)

Medical Assistance (MA) Parental Fee Form DHS-2981 (PDF)

State Agency Appeals Summary DHS-0035 (PDF)

Variance Request DHS-3141 (PDF)

Home Care Forms - Back to top

Home Care Bill of Rights DHS-4449 (PDF)
Home Care Shared Services Agreement (HCN or PCA) DHS-5899 (PDF)

MA Home Care Technical Change Request DHS-4074 (PDF)
MA Home Care Nursing Assessment DHS-4071A (PDF)
MA Home Care Nursing Assessment Instructions DHS-4071B (PDF)
MA Home Care Nursing Service Decision Tree DHS-4071C (PDF)

Managed Care Organization/County/Tribal Agency Communication Form - Authorization of Home Care Services DHS-5841 (PDF)
Home Care Nursing (HCN) Hardship Waiver Application DHS-4109 (PDF)

Screening Forms - Back to top

AC, EW, CADI & BI Waiver Case Mix Classification Worksheet DHS-3428-B (PDF)
Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147A (PDF)

Completing the Case Manager's Guide to Determining ICF/DD Level of Care DHS-4147B (PDF)
Consent for the Release of Your Name to a Center for Independent Living (CIL) DHS-3428E (PDF)

DD Screening Document DHS-3067 (PDF)
Evaluative Report: Level II Preadmission Screening for Persons with Developmental Disabilities or Related Conditions DHS-4248 (PDF)
Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS DHS-4625 (PDF)
Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSHO and MSC+ Programs DHS-4669 (PDF)

Instructions for Completing and Entering the LTCC Screening Document into MMIS for SNBC DHS-5020A (PDF)

LTC Screening Document - AC, BI, CAC, CADI, EW, MSC+, MSHO, SNBC DHS-3427 (PDF)

LTC Screening Document - Telephone Screening DHS-3427T (PDF)

LTCC cost report for face-to-face assessments of persons under 65 years DHS-5150 (PDF)

LTCC Services Assessment Form DHS-3428 (PDF)

LTCC Services Assessment Form – SW Section DHS-3428A (PDF)

LTCC Services Form: Supplemental Form for Assessment of Children under 18 DHS-3428C (PDF)
MHCP Request for Payment of Long-Term Care Services DHS-3543 (PDF)

Nursing Facility Level of Care Preadmission Screening and Community Assessment Instructions DHS-3361 (PDF)
OBRA Level I Criteria Screening for Developmental Disabilities or Mental Illness DHS-3426 (PDF)
Related Conditions Checklist DHS-3848 (PDF)

Related Conditions Checklist - Instructions DHS-3848A (PDF)

Waiver Provider Enrollment Forms - Back to top

Direct Deposit/Electronic Funds Transfer DHS-3725 (PDF)
Electronic Funds Transfer Bank Change Form (PDF)

Disclosure of Ownership DHS-5259 (PDF)

MHCP Provider Agreement DHS-4138 (PDF)

Waiver and Alternative Care (AC) Programs – Provider Enrollment Application DHS-4015 (PDF)

Waiver and Alternative Care (AC) Programs Service Request Form DHS-6638 (PDF)
MinnesotaHelp.info® instructional guide DHS-6933 (PDF)

Waiver Forms - Back to top

Additional Square Footage Approval Request DHS 5887 (PDF)
BI Waiver Assessment and Eligibility Determination DHS-3471 (PDF)
BI Waiver Assessment and Eligibility Determination Checklist DHS-3471B (PDF)

BI Waiver Assessment and Eligibility Determination Instructions DHS-3471A (PDF)

CAC Application/Reassessment Support Plan DHS-3614 (PDF)

CAC Application/Reassessment Support Plan Instructions DHS-3614A (PDF)
Caregiver Living Expenses Worksheet DHS-4929 (PDF)
Case manager's cost report for DD full team screenings DHS-6768 (PDF)

CDCS Alternative Treatment Form for MHCP-Enrolled Physicians DHS-5788 (PDF)

Community Support Plan DHS-4166 (PDF) (AC, EW, CADI, and BI Waivers)
DD Waiver Extended Safety Net Funding (Court Committed) DHS-5587B (PDF)

DD Waiver Safety Net Funding Request (Court committed) DHS-5587A (PDF)

HCBS Waiver/AC Programs Lead Agency Provider Enrollment Request Form DHS 6383 (PDF)

LTSS Assessment and Program Information and Signature Sheet DHS-2727 (PDF)

MnCHOICES Community Support Plan Worksheet DHS-6791A (PDF)

MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan DHS-6791B (PDF)

Instructions to Complete the MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan (DHS-6791B) DHS-6791C (PDF)

MnCHOICES Coordinated Services and Supports Plan Signature Sheet DHS-6791D (PDF)

Notice of Action Home and Community Based Waiver Services and AC Program DHS-2828 (PDF)

Request to Close or Develop New Corporate Foster Care (and Community Residential Settings) DHS-6021 (PDF)

Supplemental Waiver PCA Assessment and Service Plan DHS-3428D (PDF)
Waiver and Alternative Care (AC) Programs - Provider Enrollment Application DHS-4015 (PDF)

Miscellaneous Forms - Back to top

Authorization Request for Mobility Devices DHS-4315 (PDF)
Civil Rights Complaint Form: Discrimination in Service Delivery DHS-2807 (PDF)

Informed Consent Form for Psychotropic Medication(s) Use DHS-4298 (PDF)

Maltreatment of Minors and Licensing Violations Report Form DHS-4293 (PDF)
Medical Assistance for Employed Persons with Disabilities (MA-EPD) Initial Premium Notice DHS-3547 (PDF)
MHCP Hospice Transaction Form DHS-2868 (PDF)
Notice of Summary Disposition- Abuse /Neglect did Not Occur; Protective Services Not Needed DHS-4587 (PDF)

Psychotropic Medication Use Checklist for 245B Licensed Programs DHS-4254 (PDF)

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© 2017 Minnesota Department of Human Services Updated: 3/13/17 5:03 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 3/13/17 5:03 PM