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Minnesota Department of Human Services ICF/DD Manual
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ICF/DD Forms

A DHS eDocs database allows you to search for and download additional DHS forms, applications and other documents in 10 non - English languages. Information on Documents and written materials in other languages.

Billing and MMIS-related forms

General forms

ICF/DD specific forms

Miscellaneous forms

Screening forms

Billing and MMIS-related forms

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Day Training and Habilitation Service Agreement DHS-2638 (PDF)
MHCP Individual Practitioner – Provider Enrollment Application DHS-4016 (PDF)

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

General forms

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Appeal to State Agency DHS-0033 (PDF) | Instructions to Appeal to State Agency DHS-0033A (PDF)
Health Care Application Inter-Agency Transfer Form DHS-3195 (PDF)

Maltreatment/Licensing Report Form DHS-4293 (PDF)
State Agency Appeals Summary DHS-0035 (PDF)

Variance Request DHS-3141 (PDF)

ICF/DD specific forms

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Extended Therapeutic Days Application DHS-4677E (PDF)
Income and Expense Report (Excel fillable version) (PDF)
Local System Needs Plan Amendment DHS-4677C (PDF)

Occupancy Report (PDF)

Physician Recertification DHS-1743 (PDF)

Proposal of Changes to an ICF/DD DHS-4677H (PDF)
(Closure, downsizing and/or relocation)
Provider Application for 186 Special Needs Funding DHS-4677D (PDF)

Services During the Day Option Agreement DHS-4677G (PDF)

Services During the Day Option Application DHS-4677F (PDF)

Variable Rate Recommendation Form and Instructions DHS-4677A (PDF)

Variable Rate Quarterly Reporting Form and Instructions DHS-4677B (PDF)

Miscellaneous forms

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Authorization Request for Wheelchairs, Scooters and Accessories DHS-4315 (PDF)
Civil Rights Complaint Form: Discrimination in Service Delivery DHS-2807 (PDF)

Death and Serious Injury Reporting

Targeted Case Management (TCM) Data Transmittal Form DHS-3152 (PDF) - Obsoleted

Screening forms

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Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147A (PDF) | Instructions for CMs Guide to Determining ICF/DD and DD Waiver DHS-4147B (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

Physician Certification DHS-1503 (PDF)

Pre-Admission Screening and Assessment (PAS) Program Level 1: Screening for Mental Illness or Developmental Disability DHS-3426 (PDF)

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

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© 2017 Minnesota Department of Human Services Updated: 9/25/17 11:20 AM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 9/25/17 11:20 AM