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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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A to Z of DSD forms

A | B | C | D | E | H | I | L | M | N | O | P | S | V | W

A

AC, BI, CADI and EW Case Mix Classification Worksheet DHS-3428B (PDF)
Additional Square Footage Approval Request DHS-5887 (PDF)

Annual Review of Ward under Public Guardianship, DHS-5836

Appeal to State Agency DHS-0033 (PDF)
DSD Application for Emergency Disaster Assistance, DHS-6566 (PDF)
Application for Disability Services Innovative Grants, DHS-3802A (PDF)
and sample contract (PDF)
Authorization Request for Mobility Devices DHS-4315 (PDF)

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B

Behavior Intervention Reporting Form, DHS-5148 and instructions (PDF)
BI Waiver Assessment and Eligibility Determination DHS-3471 (PDF)

BI Waiver Assessment and Eligibility Determination Instructions/worksheet DHS-3471A (PDF)
BI Waiver Assessment and Eligibility Determination Checklist DHS-3471B (PDF)

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C

Caregiver Living Expenses Worksheet DHS-4929 (PDF)
Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147A (PDF)

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

CDCS Community Support Plan Addendum with Provider Rate Increase, DHS-6633A (PDF)

Civil Rights Complaint Form: Discrimination in Service Delivery DHS-2807 (PDF)

CAC Application/Reassessment Support Plan DHS-3614 (PDF)
CAC Application/Reassessment Support Plan Instructions DHS-3614-A (PDF)
Community Support Plan DHS-4166 (PDF)

Consent for the Release of Your Name to a Center for Independent Living (CIL) DHS-3428E (PDF)
County of Financial Responsibility Transfer for FSG DHS-4007 (PDF)

County Parental Fee Referral to DHS DHS-2982 (PDF)

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D

Day Training and Habilitation (DT&H) Services Determination of Need Application for Expansion, DHS-4960A (PDF)
Day Training and Habilitation (DT&H) Services Determination of Need Application for Proprietary Changes, Reductions and Closures, DHS-4960B (PDF)

Day Training and Habilitation Service Agreement DHS-2638 (PDF)

DD Waiver Extended Safety Net Funding (Court Committed) DHS-5587B (PDF)

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

DD Waiver Waiting List Category Determination Tool, DHS-7209 (PDF)

Developmental Disability (DD) Screening Document DHS-3067 (PDF)

Disability Waiver Rates System Exception Request, DHs-5820
and instructions (PDF)
DWRS Rates Mentor Inquiry Form, DHS-7012

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E

EIDBI Advisory Group Agenda Submission Form, DHS-3807 (PDF)
EIDBI Authorization Request, DHS-3806 (PDF)
and instructions (PDF)
EIDBI Technical Change Request, DHS-6516 (PDF)
and instructions (PDF)
Evaluative Report: Level II Preadmission Screening for Persons with Developmental Disabilities or Related Conditions DHS-4248 (PDF)

Exception to CDCS Budget Methodology, DHS-6633 (PDF)

Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers), DHS-5504B (PDF)

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H

HCBS Provider Attestation, DHS-7176
HCBS Waiver/AC Programs Lead Agency Provider Enrollment Request Form DHS-6383 (PDF)

Home Care Nursing (HCN) Hardship Waiver Application DHS-4109 (PDF)

Home Care Nursing Service Decision Tree DHS-4071C (PDF)
Host County Notification of Residential Placement Form, DHS-7418 (PDF)

Housing Access Coordination Exception Request for people with criminal, subpar credit or eviction history, DHS-6218 (PDF)

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I

ICF/DD Local System Needs Plan Amendment, DHS-4677C (PDF)
Information and Signature Sheet for PAS\ EW\ AC\ CAC\ CADI\ TBI DHS-2727 (PDF)

Instructions for Case Managers Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147B (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)

Inter Agency Case Transfer Form DHS-3195 (PDF)

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L

Long Term Care Consultation Services Assessment Form DHS-3428 (PDF)
Long Term Care Consultation Services Assessment Form - SW Section DHS-3428A (PDF)
Long Term Care Consultation Services Form: Supplemental Form for Assessment of Children under 18 DHS-3428C (PDF)
LTC Screening Document - AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO, SNBC DHS-3427 (PDF)
LTC Screening Document - Telephone Screening DHS-3427T (PDF)

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M

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)
Maltreatment of Minors and Licensing Violations Report Form DHS-4293 (PDF)

Managed Care Organization/County/Tribal Agency Communication Form - Authorization of Home Care Services - DHS-5841 (PDF)
Medical Assistance for Employed Persons with Disabilities (MA-EPD) Initial Premium Notice DHS-3547 (PDF)

Medical Assistance Parental Fee Form DHS-2981 (PDF)
Minnesota Health Care Programs Hospice Transaction Form DHS-2868 (PDF)
Minnesota Health Care Programs Provider Enrollment Application and Instructions - DHS-4016 (PDF)

MinnesotaHelp.info® instructional guide DHS-6933 (PDF)
MHCP Organization - Provider Enrollment Application DHS-4016A (PDF)

MnCHOICES Case Manager's Recipient Information Form, DHS-7185

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

MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan DHS-6791B (PDF)
and Instructions, DHS-6791B (PDF)
MnCHOICES Coordinated Services and Supports Plan Signature Sheet DHS-6791D (PDF)

MnCHOICES Help Desk Contact Form, DHS-6979

MnCHOICES Reassessment Communication Form, DHS-6791E (PDF)
and instructions, 6791F (PDF)
Monitoring Technology Approval Request Process forms, DHS-6789 (PDF)

Moving Home Minnesota Communications Form DHS-6759H (PDF)

Moving Home Minnesota Informed Consent Form DHS-6759I (PDF)

Moving Home Minnesota Housing Transitions Worksheet DHS-6759G (PDF)

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N

Notice of Action Home and Community Based Waiver Services DHS-2828 (PDF)
Nursing Facility Level of Care Preadmission Screening and Community Assessment Instructions DHS-3361 (PDF)

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O

Olmstead Employment Practice Review Panel Story Template, DHS-7279 (PDF)

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P

PCA Request Fax Form, DHS-4292 (PDF)
Pre-Admission Screening and Assessment (PAS) Program Level 1: Screening for Mental Illness or Developmental Disabilities DHS-3426 (PDF)

Positive Support Transition Plan instructions DHS-8610B (PDF)
Positive Support Transition Plan review DHS-6810A (PDF)

Positive Support Transition Plan template DHS-6810 (PDF)

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R

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

Request for Medicaid Administrative Reimbursement or Reimbursement for Alternative Care form, DHS-5504 (PDF)

Request for Payment of Long-Term Care Services DHS-3543 (PDF)

Request to develop new Corporate Foster Care (and Community Residential Settings)

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S

Service Agreement DHS-3070 (PDF) and instructions
State Agency Appeals Summary DHS-0035 (PDF)

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V

Variance Request Form DHS-3141 (PDF)
Voluntary Closure Application: Corporate Adult Foster Care Planned Closure DHS-6021B (PDF)

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W

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

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Additional resources

CBSM – Forms by number

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© 2017 Minnesota Department of Human Services Updated: 9/4/17 10:14 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 9/4/17 10:14 PM