CFSS forms and documents
Page updated: 2/11/26
DHS is working to post new forms and documents for CFSS. This page describes the available forms and gives instructions for use.
To find a form or document, use DHS – Searchable document library (eDocs) and search by the number.
Published forms and documents
Title | Who uses it | When to use it | Notes | Related resources |
CFSS Assessment, DHS-6893A and Instructions for CFSS Assessment, DHS-6893A | Assessor in a county approved to use DHS-6893A in place of MnCHOICES (in some circumstances) | To complete a reassessment for a person not eligible for a waiver/Alternative Care (AC) | DHS-6893A replaced: The instructions replaced PCA Assessment and Service Plan Instructions and Guidelines, DHS-3244A. | |
60 days before the end of the current authorization | DHS-6893B replaced Referral for Reassessment for PCA Services, DHS-3244P. | |||
CFSS Worker Time and Activity Documentation, DHS-6893C (PDF) | When the person’s provider agency/FMS provider chooses this form as one of their types of documentation | This form replaces PCA Worker Time and Activity Documentation, DHS-4691 (PDF). PCA agencies can continue to use DHS-4691 for work in PCA until the transition to CFSS is complete. | CFSS Manual – PCA/CFSS personal care time and activity documentation | |
Recommendation for Removal from the CFSS Budget Model, DHS-6893D (PDF) | Consultation services provider | When recommending DHS remove a person from the budget model who is not fulfilling their employer responsibilities Note: The consultation services provider must attempt to help the person before using DHS-6893D. | This form is new for CFSS. | CFSS Manual – PCA/CFSS process to change service options/models |
Home Care Shared Services Agreement (HCN, PCA or CFSS), DHS-6893E (PDF) | When the person uses shared services | DHS-6893E replaced Home Care Shared Services Agreement (HCN or PCA), DHS-5899. | ||
PCA Program Responsible Party Form/CFSS Participant Representative Agreement, DHS-6893F | When the person has a participant’s representative | DHS-6893F replaced PCA Program Responsible Party Form, DHS-5856. | CFSS Manual – Responsible party (PCA) and participant’s representative (CFSS) | |
CFSS Program Information and Signature Sheet, DHS-6893G (PDF) or translations: | Assessor in a county approved to use DHS-6893A in place of MnCHOICES (in some circumstances) | When using DHS-6893A in place of MnCHOICES | DHS-6893G replaced LTSS Assessment and Program Information and Signature Sheet, DHS-2727, which was a form previously used for MnCHOICES. | N/A |
Any interested parties | When interested in how the assessment determines the person’s home care rating and units | DHS-6893H replaced Personal Care Assistance (PCA) Decision Tree, DHS-4201. | ||
When requesting changes to the service agreement the county/tribal nation cannot make | This form replaces PCA Request Form, DHS-4292. Counties and tribal nations must continue to use DHS-4292 to submit requests for changes to PCA services. | CFSS Manual – Resource: CFSS mid-year changes for counties and tribal nations | ||
When requesting changes to the service agreement not made by the county/tribal nation | This form replaces PCA Technical Change Request, DHS-4074A. PCA provider agencies must continue to use DHS-4074A to submit requests for changes to PCA services. | CFSS Manual – Resource: CFSS mid-year changes for counties and tribal nations | ||
Temporary CFSS Individual Service Delivery Plan Approval, DHS-6893L (PDF) | When temporarily authorizing the person’s current CFSS services to avoid a gap in service | This form is new for CFSS. | CFSS Manual – CFSS service delivery plan development and approval process | |
Lead agency staff | When conducting an assessment for a 45-day increase | This form is new for CFSS. | CFSS Manual – 45-day temporary increase of PCA/CFSS services | |
Consultation Services Provider CFSS Service Delivery Plan Cover Sheet, DHS-6893N | Consultation services provider | When communicating information to the lead agency about discussions the provider had with the person about elements of their CFSS service delivery plan | This form is new for CFSS. | |
Person using CFSS | When writing their CFSS service delivery plan | This form is new for CFSS. | ||
CFSS Individual Service Delivery Plan (Short Version), DHS-6893Q | Person using CFSS | When the person either: | This form is new for CFSS. | |
CFSS Rights and Responsibilities, DHS-6893R-ENG (PDF) or translations: | Before starting services with the person | Providers and lead agencies use this form instead of Home Care Bill of Rights (PDF). | ||
CFSS Consultation Services Session Documentation, DHS-6893S (PDF) | Consultation services provider | After providing consultation services sessions; keep on file for each session billed Note: The consultation services provider can use an alternative form if it contains all the same information. | This form is new for CFSS. | |
Worker Information for CFSS Budget Model, DHS-6893T (PDF) or translations: | Person using the budget model | When documenting completion of employer responsibilities for each CFSS worker | This form is new for CFSS. | |
Information for people who use CFSS, DHS-6893U (PDF) or translations: | Lead agency staff | After determining the person is eligible for CFSS | This document is a new fact sheet that lead agencies give to people who are eligible for and select CFSS. | N/A |
Lead agency addendum to CFSS Individual Service Delivery Plan, DHS-6893W | Lead agency staff | When authorizing services or service changes Note: Managed care organizations (MCOs) can use an alternative form if it contains all the same information. | This form is new for CFSS. Lead agencies: | CFSS Manual – CFSS service delivery plan development and approval process |
CFSS Information Sheet – English, DHS-8477A-ENG (PDF) or translations: | Lead agency staff | After determining a person currently using PCA/CSG is eligible for CFSS | This document is a new one-page fact sheet with general information about CFSS. | N/A |
AC/EW CFSS/PCA Enhanced Rate Budget Exception Request, DHS-8243 (PDF) | Lead agency staff | When requesting an enhanced rate budget exception for people using CFSS on Alternative Care (AC) or the Elderly Waiver (EW) | N/A | |
Lead Agency Communication Form: Recommendation for State Plan Home Care Services, DHS-5841 | Lead agency staff | When county/tribal nation workers and MCO workers need to communicate with each other about CFSS services | N/A | N/A |
PCA/CFSS Cost Reporting Time-Study Worksheet, DHS-7190B (PDF) | Provider agencies | When tracking cost reporting requirements | This form is optional. |
Other forms
People who wish to appeal the results of their assessment may use Appeal to State Agency, DHS-0033.
Certified assessors, case managers and care coordinators must complete applicable forms on CBSM – Documents for long-term services and supports (LTSS) assessment, eligibility and support planning.
CFSS providers must complete all required Minnesota Health Care Programs (MHCP) forms. For more information, refer to MHCP Provider Manual – Enrollment with MHCP.
Unpublished forms
DHS is completing work on the following CFSS form. We will add a link when it is available.
Form name | Who uses it | When to use it | Notes |
Consultation Services Orientation Checklist, DHS-6893J | Consultation services provider | When educating the person about CFSS | This will be a new optional form. |
Retired forms
PCA Communication to Physician of PCA Services, DHS-4690 is no longer required in CFSS.
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