Forms by number

Frequently used forms listed by DHS form number.

To access all DHS forms, go to the DHS eDocs site.

Documents and written materials in other languages | Forms | A to Z of DSD Forms

DHS-0033 Application to State Agency
DHS-0035 State Agency Appeals Summary
DHS-2638 Day Training and Habilitation Service Agreement (PDF)
DHS-2807 Civil Rights Complaint Form: Discrimination in Service Delivery (PDF)
DHS-2828A LTSS Notice of Action (Assessments and Reassessments)
DHS-2828B LTSS Notice of Action – Explanation of Changes to Your Support Plan
DHS-2828C Notice of Temporary Service Suspension (PDF)
DHS-2828D Notice of Service Termination (PDF)
DHS-2868 MHCP Hospice Transaction Form (PDF)
DHS-2981 Medical Assistance (MA) Parental Fee Form (PDF)
DHS-2982 County Parental Fee Referral to DHS (PDF)
DHS-3067 DD Screening Document
DHS-3070 Service Agreement (PDF)
DHS-3141 Variance Request (PDF)
DHS-3195 Inter Agency Case Transfer Form (PDF)
DHS-3426 OBRA Level I Criteria – Screening for Developmental Disabilities or Mental Illness
DHS-3427 LTC Screening Document – AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO (PDF)
DHS-3427T LTC Screening – Telephone Screening (PDF)
DHS-3428B AC, EW, CADI & BI Waiver Case Mix Classification Worksheet (PDF)
DHS-3471 BI Waiver Assessment and Eligibility Determination (PDF)
DHS-3471A BI Waiver Assessment and Eligibility Determination Instructions (PDF)
DHS-3471B BI Waiver Assessment and Eligibility Determination Checklist (PDF)
DHS-3543 MHCP Request for Payment of Long-Term Care Services (PDF)
DHS-3547 MA-EPD Initial Premium Notice (PDF)
DHS-3754 Service Agreement and Screening Document (SASD) Support Team Portal
DHS-3806 EIDBI Authorization Request
DHS-3806A Instructions for MHCP: EIDBI Authorization Request form (PDF)
DHS-3807 EIDBI Advisory Group Agenda Submission Form (PDF)
DHS-3848 DSD Related Conditions Checklist (PDF)
DHS-3848A DSD Related Conditions Checklist - Instructions (PDF)
DHS-4007 County of Financial Responsibility Transfer for FSG (PDF)
DHS-4015 HCBS Provider Enrollment Application (PDF)
DHS-4016 MHCP Individual Practitioner Provider Enrollment Application (PDF)
DHS-4016A MHCP Organization - Provider Enrollment Application (PDF)
DHS-4022 MHCP PCPO/PCA Choice Agency Enrollment Application (PDF)
DHS-4022A MHCP Provider Agreement Addendum – PCPO (PDF)
DHS-4022B MHCP Provider Agreement Addendum - PCA Choice Provider (PDF)
DHS-4022C MHCP Qualified Professional (QP) Acknowledgement (PDF)
DHS-4071A MA Home Care Nursing Assessment (PDF)
DHS-4071B MA Home Care Nursing Assessment Instructions (PDF)
DHS-4071C Home Care Nursing Service Decision Tree (PDF)
DHS-4074 MA Home Care Technical Change Request
DHS-4074A PCA Technical Change Request
DHS-4109 HCN Hardship Waiver Application (PDF)
DHS-4138 MHCP Provider Agreement (PDF)
DHS-4147A Case Manager’s Guide to Determining ICF/DD LOC for ICF/DD and DD Waiver (PDF)
DHS-4147B Instructions for Case Managers Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services (PDF)
DHS-4248 OBRA Level II evaluative report for people with developmental disabilities or related conditions
DHS-4248A OBRA Level II evaluative report signature sheet (PDF)
DHS-4254 Psychotropic Medication Use Checklist for 245B Licensed Programs (PDF)
DHS-4292 PCA Request Form
DHS-4315 Authorization Request for Mobility Devices (PDF)
DHS-4625 Instructions for Completing and Entering the LTC Screening Document and SA (PDF)
DHS-4669 Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSHO and MSC+ Programs (PDF)
DHS-4677C ICF/DD Local System Needs Plan Amendment (PDF)
DHS-4691 PCA Time and Activity Documentation (PDF)
DHS-4929 Caregiver Living Expenses Worksheet (PDF)
DHS-4960A Day Training and Habilitation (DT&H) Services Determination of Need Application for Expansion (PDF)
DHS-4960B Day Training and Habilitation (DT&H) Services Determination of Need Application for Proprietary Changes, Reductions and Closures (PDF)
DHS-5020A Instructions for Completing and Entering the HRA for SNBC (PDF)
DHS-5148 Behavior Intervention Reporting Form and instructions (PDF)
DHS-5259 MHCP Disclosure of Ownership and Control Interest of an Entity
DHS-5504 Requesting Medicaid Administrative Reimbursement or Reimbursement for AC
DHS-5504B Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers)
DHS-5504C Exception Request Checklist for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD Waivers) (PDF)
DHS-5788 CDCS Alternative Treatment Form for MHCP-Enrolled Physicians (PDF)
DHS-5820 Disability Waiver Rates System Exception Request and instructions (PDF)
DHS-5836 Annual Review of Ward under Public Guardianship
DHS-5841 MCO/County/Tribal Agency Communication Form – Recommendation for State Plan Home Care Services
DHS-5887 Additional Square Footage Approval Request (PDF)
DHS-6000 MHCP Designation of PCA Billing Person (PDF)
DHS-6005 MHCP PCA Agency Applicant Assurance Statement (PDF)
DHS-6021 Request to develop new Corporate Foster Care (and Community Residential Settings)
DHS-6021B Voluntary Closure Application: Corporate Adult Foster Care Planned Closure
DHS-6033 MHCP PCA Agency Surety Bond (PDF)
DHS-6041 MHCP PCA Agency Personnel List and Affiliation (PDF)
DHS-6383 HCBS Waiver/AC Programs Lead Agency Provider Enrollment Request Form (PDF)
DHS-6532 CDCS Community Support Plan
DHS-6566 DSD Application for Emergency Disaster Assistance (PDF)
DHS-6633 Exception to CDCS Budget Methodology (PDF)
DHS-6633A CDCS Community Support Plan Addendum with Provider Rate Increase (PDF)
DHS-6759G Moving Home Minnesota Housing Transitions Worksheet
DHS-6759H Moving Home Minnesota Communications Form
DHS-6759I Moving Home Minnesota Informed Consent Form (PDF)
DHS-6759J Moving Home Minnesota Transition Planning Tool
DHS-6759K Moving Home Minnesota Transition Planning Tool, Part 2: Risk Mitigation (PDF)
DHS-6768 Case manager's cost report for DD full team screenings (PDF)
DHS-6789 List of Monitoring Technology Approval Request Process forms (PDF) [includes 6789A, 6789B and 6789C]
DHS-6791A MnCHOICES Assessment Summary Worksheet (PDF)
DHS-6791B MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan
DHS-6791C Instructions to Complete the MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan (DHS-6791B) (PDF)
DHS-6791E MnCHOICES Reassessment Communication Form and instructions (PDF)
DHS-6810 Positive Support Transition Plan Template and instructions (PDF)
DHS-6810A Positive Support Transition Plan Review
DHS-6810D: Request for the Authorization of the Emergency Use of Procedures
DHS-6810F: Positive Supports Functional Behavior Assessment Quality Checklist
DHS-6810G: Positive Support Transition Plan Quality Checklist
DHS-6893A: CFSS Assessment
DHS-6893B: Referral for Reassessment for PCA/CFSS Services
DHS-6893C: CFSS Worker Time and Activity Documentation (PDF)
DHS-6893D: Recommendation for Removal from the CFSS Budget Model
DHS-6893E: Home Care Shared Services Agreement (HCN, PCA or CFSS) (PDF)
DHS-6893F: PCA Program Responsible Party Form/CFSS Participant Representative Agreement (PDF)
DHS-6893G: CFSS Program Information and Signature Sheet (PDF)
DHS-6893H: CFSS Home Care Rating/Units Reference Tool (PDF)
DHS-6893I: CFSS Request Form
DHS-6893K: CFSS Technical Change Request
DHS-6893L: Temporary CFSS Individual Service Delivery Plan Approval (PDF)
DHS-6893N: Consultation Services Provider CFSS Service Delivery Plan Cover Sheet
DHS-6893P: CFSS Individual Service Delivery Plan
DHS-6893R: CFSS Rights and Responsibilities (PDF)
DHS-6893S: CFSS Consultation Services Session Documentation (PDF)
DHS-6893T: Worker Information for CFSS Budget Model
DHS-6893U: Information for People Who Use CFSS (PDF)
DHS-6893W: Lead Agency Addendum to CFSS Individual Service Delivery Plan
DHS-6910 Rates Management (RMS) Residential Shared Staffing Hours Worksheet (PDF)
DHS-6939 MA-EPD Good Cause Application and instructions (PDF)
DHS-6940 MnCHOICES PCA Service Agreement Addendum (PDF)
DHS-6979 MnCHOICES Help Desk Contact Form
DHS-7108 CMDE Medical Necessity Summary Information
DHS-7109 Individual Treatment Plan (ITP) and Progress Monitoring
DHS-7109A I EDBI Transition and/or Discharge Summary
DHS-7109C ITP and Progress Monitoring Week-in-the-Life Schedule (Addendum C) (PDF)
DHS-7176 HCBS Provider Attestation
DHS-7176H HCBS Rights Modification Support Plan Attachment
DHS-7185 Case Manager's Recipient Information Form
DHS-7209 DSD DD Waiver Waiting List Category Determination Tool (PDF)
DHS-7279 Olmstead Employment Practice Review Panel Story Template (PDF)
DHS-7418 Host County Notification of Residential Placement Form (PDF)
DHS-7634A Maltreatment of Minors Mandated Reporting (PDF)
DHS-7759A Remote Support Exception Form
DHS-7759B Customized Living Size-Limit Exception Request Form
DHS-7759E Safety Checklist for Out-of-Home Respite Services in an Unlicensed Setting (PDF)
DHS-8062 Setting Capacity Report
DHS-8168 DSD Contact Form
DHS-8477 CFSS Information Sheet (PDF)