EIDBI benefit forms
Page updated: 8/7/25
This page includes information about forms for:
Form | When and how to use it | Where to submit | Helpful resources |
CMDE Medical Necessity Summary Information, DHS-7108 (PDF) and translated signature pages: | The CMDE provider uses this form to document the results of the person’s CMDE. | Submit the completed CMDE to the state medical review agent or the person’s corresponding health plan. For more information, refer to MHCP Provider Manual – EIDBI – Service authorization. | How to complete CMDE Medical Necessity Summary Information, DHS-7108 |
ITP and Progress Monitoring, DHS-7109 (PDF) with the optional Addendum C – Week-in-the-Life Schedule, DHS-7109 (PDF) and translated signature pages: | The qualified supervising professional (QSP) uses this form to document the person’s ITP and progress monitoring updates. | Submit the completed ITP to the state medical review agent for service authorization before the person can begin to receive or continue to receive EIDBI services. | |
The EIDBI provider agency should use this form to develop and update a person’s safety plan. | Keep a copy of this resource in the person’s file. Do not submit it to DHS. | ||
The EIDBI provider agency uses this form when a person transitions locations within the agency or discharges from the agency. | Submit the completed form to the state medical review agent or the person’s corresponding health plan. | ||
Your rights and responsibilities, DHS-7645A (PDF) and EIDBI provider agency responsibilities, DHS-7645B (PDF) or translated versions: | The QSP uses these forms to inform the person and their legal representative of their rights and responsibilities and explain the EIDBI provider agency’s responsibilities. | The QSP must provide the person with a written copy and verbal explanation of these documents. The provider must keep the updated, signed document in the person’s file. | |
The EIDBI provider agency uses this form to request authorization for EIDBI services that exceed the service limit threshold (e.g., additional CMDE in a calendar year, additional coordinated care conference in a calendar year). All service limits are listed on the EIDBI Billing Grid (PDF). The services requested on DHS-3806 must exceed the service limit threshold and not be previously requested as part of the ITP, DHS-7109. The provider must consult with the person’s parent/legal representative about the request. The parent/legal representative's signature of this form indicates that they approve the request. | Submit the completed form to the state medical review agent or the person’s corresponding health plan. | Instructions to complete the EIDBI Authorization Request form, DHS-3806A (PDF) | |
Anyone can use this form to request a revision to the DHS-recognized treatment modalities. | Submit the form to DHS using the “submit” button on the form or by emailing it to asd.dhs@state.mn.us. | ||
Supplemental resource: Family Caregiver Checklist, DHS-6751B (PDF) or translated versions: | EIDBI providers use this form to share information about the person and family/caregiver with internal staff. It can be helpful for new team members or as a quick reference. | Keep a copy of this resource in the provider’s file. Do not submit it to DHS. | |
Supplemental resource: Case Example Handout Exercises, DHS-6751F (PDF) or translated versions: | EIDBI providers use this form as a training resource to discuss case examples. | Keep a copy of this resource in the provider’s file. Do not submit it to DHS. | |
Supplemental resource: Identifying Your Personal Perceptions of Culture, DHS-6751G (PDF) or translated versions: | Individual EIDBI providers use this form to understand their own worldview or perception of culture and what it means to them. They should take time to answer the questions and review it periodically. | Keep a copy of this resource in the provider’s file. Do not submit it to DHS. | |
Supplemental resource: Developing an Environment for Effective Service Delivery, DHS-6751H (PDF) | EIDBI providers should use this checklist to make sure they are ready to provide culturally responsive services. | Keep a copy of this resource in the provider’s file. Do not submit it to DHS. | |
Supplemental resource: Effective Evaluation and Treatment Plan Checklist for Providers, DHS-6751I (PDF) | EIDBI providers should use this guidance to be more aware of how they interact with people and their families. | Keep a copy of this resource in the provider’s file. Do not submit it to DHS. | |
Supplemental resource: EIDBI Welcome Letter for Caregivers – English (PDF) or translated versions: | EIDBI providers should share this letter with the person’s family or caregiver(s) to help them understand EIDBI services. | Share this resource with the person’s family or caregiver(s) at intake or orientation. Keep a copy of this resource in the person’s file. Do not submit it to DHS. | |
Anyone can complete and submit this form to make a referral to EIDBI services. | Submit the form to DHS by selecting the “submit” button at the end of the form. |
Report this page