Documents for long-term services and supports (LTSS) assessment, eligibility and support planning
Page updated: 4/21/25
Page comprehensively reviewed: 4/21/25
This page provides information about required documents for some LTSS programs and services. Certified assessors, case managers and care coordinators use this page to understand when and how to use these documents with MnCHOICES.
Use the following links to move to a document category:
Note: If a document is no longer used with MnCHOICES, the certified assessor can use it as a reference tool. Assessors, case managers and care coordinators must reference assessment and support planning guidance documents in the MnCHOICES help center.
For information about documents in MnCHOICES, refer to CBSM – Documents produced within the MnCHOICES application.
Acronyms on this page
This page includes the following acronyms:
Application documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Application for Social Services, DHS-2140 (PDF) or lead-agency-developed form | No | No | No | Yes, continue to use this form or equivalent form to apply for Rule 185 case management | No |
Assessment documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Mini-Cog Instructions for Admission and Scoring, DHS-3428M (PDF) | Yes, for AC, EW, BI, CAC and CADI, when applicable | No | No | Yes, when applicable and in conjunction with assessment content | When required, attach to the person record |
No | No | Yes | No, may use as a guide when assessing and authorizing requests for 45-day temporary start of service or temporary increase over the phone | No | |
No | No | Yes | No, may use as a guide when assessing and authorizing requests for 45-day temporary start of service or temporary increase over the phone | No | |
Yes, when applicable | Yes, when applicable | No | Yes, when applicable | Yes, attach to the person record | |
Medication list (lead agency-developed document) | Yes, for AC, BI, CAC, CADI and EW, when applicable | Yes, when applicable | Yes, when applicable | Yes, when available | When required, attach to the person record |
Supporting documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
AC, BI, CADI, EW Case Mix Classification Worksheet, DHS-3428B (PDF) | Yes, for AC, BI, CAC, CADI and EW | No | No | No, components are built into MnCHOICES | No |
Yes, for CAC | No | No | Yes, for CAC | When applicable, attach to the person record | |
BI Waiver Assessment and Eligibility Determination, DHS-3471 (PDF), Instructions/Worksheet, DHS-3471A (PDF) | Yes, for BI | No | No | No, components are built into MnCHOICES | No |
Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services, DHS-4147A (PDF) | Yes, for DD | No | No | No, components are built into MnCHOICES | No |
No | No | Yes | No, components are built into MnCHOICES | No | |
OBRA Level I Criteria – Screening for Developmental Disabilities or Mental Illness, DHS-3426 | Yes, for AC, BI, CAC, CADI, DD and EW | Yes, for nursing facility admit only | No | No, form exists within MnCHOICES | No |
Physician letter of medical necessity (refer to CBSM – Instructions for completing physician letter of medical necessity for the BI-NB Waiver) | Yes, for BI-NB | No | No | Yes, for BI-NB | When applicable, attach to person record |
Related Conditions Checklist, DHS-3848 (PDF) | Yes, for DD, when applicable | No | No | Yes, for DD, when applicable | When applicable, attach to person record |
Financial determination of eligibility documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Yes | Yes, for nursing facility admit only | No | Yes | No | |
Request for Payment of Long-Term Care Services, DHS-3543 (PDF) | Yes | Yes, for nursing facility admit only | No | Yes | No |
AC Program Eligibility Worksheet, DHS-2630 (PDF) | Yes, for AC | No | No | Yes, for AC | Yes |
Yes, for AC | No | No | Yes, for AC | No | |
Yes, for AC | No | No | Yes, for AC | No | |
Essential Community Supports (ECS) Financial Eligibility Worksheet, DHS-6683 (PDF) | Yes, for ECS | No | No | Yes, for ECS | Yes |
Yes, for ECS | No | No | Yes, for ECS | No | |
About the MnCHOICES documents you are receiving, DHS-6791K (PDF) | No | No | No | Yes, as applicable for both assessment and support plan | No |
Support planning documents
For information about roles and the support planning process, refer to CBSM – Support planning for LTSS.
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Who completes? | Attach in MnCHOICES? |
Emergency Back-Up Plan (PDF) (resource that describes components) | Yes | No | No | No | Not applicable | No |
Individual Community Living Support (ICLS) Planning Form, DHS-3751 | Yes, for AC, EW | No | No | Yes | Case manager or care coordinator | Yes, attach to person record |
MMIS and billing documents
Lead agencies create the LTC and/or the DD screening document through MnCHOICES. Lead agencies can use LTC Screening Document, DHS-3427 (PDF) or DD Screening Document, DHS-3067 for reference. For changes not related to an assessment, lead agencies should use DHS-3427 or DHS-3067 for updates as needed. For more information, refer to Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF) or the DD Screening Document Codebook.
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Yes, for DD | No | No | No, built into MnCHOICES Note: Users access this document for administrative changes made outside of MnCHOICES. | No | |
LTC Screening Document – AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO, SNBC, DHS-3427 (PDF) | Yes, for AC, BI, CAC, CADI, ECS and EW | No | No | No, built into MnCHOICES Note: Users access this document for administrative changes made outside of MnCHOICES. | No |
Yes, for fee-for-service AC, BI, CAC, CADI, DD, ECS and EW | No | No | No, built into MnCHOICES Note: Counties and tribal nations use this document for reference only. | No |
Appeals documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No | Yes | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No | |
Appeal Summary for Long-Term Services and Supports, DHS-6807 (PDF) | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No | Yes | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No |
LTSS Notice of Action (Assessments and Reassessments), DHS-2828A Note: For information about when it is appropriate to use this form, refer to CBSM – Notice of action. | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No | Yes | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS, EW Note: Users access this document for administrative changes made outside of MnCHOICES. | Yes, when completed outside of MnCHOICES |
LTSS Notice of Action (Service Plan), DHS-2828B Note: For information about when it is appropriate to use this form, refer to CBSM – Notice of action. | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | No | Yes | Yes, by counties and tribal nations for AC, BI, CAC, CADI, DD, ECS and EW | Yes |
Your Appeals Rights, DHS-1941 (PDF) or lead-agency-developed form | Yes | No | Yes | Yes | No |
Other documents
Supplemental document name | Used with legacy assessment processes? | Used with legacy health risk assessment? | Used for CFSS? (limited use ONLY for specific contracted agencies) | Used with MnCHOICES? | Attach in MnCHOICES? |
Yes | No | No | Yes | No | |
MnCHOICES Reassessment Communication Form, DHS-6791E | Yes | Yes | No | Yes | No |
If applicable, nursing facility admit only | If applicable, nursing facility admit only | If applicable, lead agency staff complete for nursing facility admit only | Yes, nursing facility admit only | No | |
Pre-Admission Screening and Resident Review (PASRR) Level II Mental Health Tool | If applicable, nursing facility admit only | If applicable, nursing facility admit only | If applicable, lead agency staff complete for nursing facility admit only | Yes, nursing facility admit only | No |
Recommendation for State Plan Home Care Services, DHS-5841 | Yes | Yes | No | Yes | No |
Notice of Privacy Practices, DHS-3979 (PDF) or lead-agency-developed form | Yes | Yes | Yes | Yes | No |
MnCHOICES Lead Agency Transfer and Communication Form, DHS-6037 (PDF) | Yes | Yes | No | Yes | No |
Informed consent to share/release information (lead agency-developed document) | Yes | Yes | Yes | Yes | No |
Notice of Privacy Practices and Notice of Rights and Responsibilities, DHS-4839E or lead-agency-developed document | Yes | Yes | Yes | Yes | No |
Yes | Yes, as applicable | Yes, as applicable | Yes, required for all assessments for DD Waiver As applicable for all other waivers/programs | No | |
No | Yes, as applicable | Yes, as applicable | Yes, as applicable | No | |
No | Yes, as applicable | Yes, as applicable | Yes, as applicable | No | |
Yes, for EW, as applicable | No | No | Yes, for EW, as applicable | Yes | |
AC/EW PCA/CFSS Enhanced Rate Budget Exception Request, DHS-8243 (PDF) | Yes, for AC/EW, as applicable | No | No | Yes, for AC/EW, as applicable | Yes |
Additional resources
For information about documents in MnCHOICES, refer to CBSM – Documents produced within the MnCHOICES application.
For service-specific required forms, refer to:
For program/service information, refer to:
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