Forms and documents

This page provides a list of frequently used DHS forms referenced in the CBSM. Use the DHS eDocs searchable document library to search for and download forms, applications and other documents in other languages.

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General | Billing and MMIS | Early Intensive Developmental and Behavioral Intervention (EIDBI) | home care | long-term services and supports (LTSS) assessment, eligibility and support planning) | personal care assistance (PCA) and Community First Services and Supports (CFSS) | positive supports | waivers – lead agencies | waivers – providers | miscellaneous

General

Appeal to State Agency, DHS-0033
County of Financial Responsibility Transfer for FSG, DHS-4007 (PDF)
County Parental Fee Referral, DHS-2982
Interagency Case Transfer Form, DHS-3195 (PDF)
MA Parental Fee Form, DHS-2981 (PDF)
State Agency Appeals Summary, DHS-0035 (PDF)
Variance Request, DHS-3141

Billing and MMIS

Day Training and Habilitation Service Agreement, DHS-2638 (PDF)
MHCP Qualified Professional Acknowledgement, DHS-4022C (PDF)
MHCP Individual Practitioner – Provider Enrollment Application, DHS-4016
MHCP Organization – Provider Enrollment Application, DHS-4016A (PDF)
MHCP Provider Agreement Addendum – PCPO, DHS-4022A (PDF)
MHCP Personal Care Providers Application, DHS-4022 (PDF)
Service Agreement, DHS-3070 (PDF)
Instructions for Completing and Entering the Health Risk Assessment into MMIS for SNBC, DHS-5020A (PDF)
Instructions for Completing and Entering the LTCC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF)
Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSC+ and MSHO Programs, DHS-4669 (PDF)

EIDBI (autism spectrum disorder and related conditions)

EIDBI Manual – Forms

Home care

Home Care Bill of Rights, DHS-4449 (PDF)
Home Care Nursing (HCN) Hardship Waiver Application, DHS-4109 (PDF)
Home Care Shared Services Agreement (HCN, PCA or CFSS), DHS-6893E (PDF)
MA Home Care Technical Change Request, DHS-4074 (PDF)
MA Home Care Nursing Assessment, DHS-4071A (PDF)
MA Home Care Nursing Assessment Instructions, DHS-4071B (PDF)
MA Home Care Nursing Service Decision Tree, DHS-4071C (PDF)
Recommendation for State Plan Home Care Services, DHS-5841 (PDF)

LTSS assessment, eligibility and support planning

CBSM – Documents for LTSS assessment, eligibility and support planning

MnCHOICES

CBSM – Documents produced within the MnCHOICES application.

PCA/CFSS

CFSS Manual – Forms and documents

Positive supports

Behavior Intervention Reporting Form, DHS-5148
Positive Supports Functional Behavior Assessment Quality Checklist, DHS-6810F
Positive Support Transition Plan, DHS-6810 and instructions, DHS-6810B (PDF)
Positive Support Transition Plan Review, DHS-6810A
Positive Support Transition Plan Quality Checklist, DHS-6810G (PDF)
Request for the Authorization of the Emergency Use of Procedures, DHS-6810D

Waivers – lead agencies

Additional Square Footage Checklist, DHS-5887 (PDF)
Caregiver Living Expenses Worksheet, DHS-4929 (PDF)
Case Manager's Cost Report for DD Full-Team Screenings, DHS-6768 (PDF)
Lead Agency Assurance Statement: HCBS Provider Review and Approval, DHS 6383 (PDF)
MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan, DHS-6791B (PDF)
Request to Close or Develop New Corporate Foster Care (and Community Residential Settings), DHS-6021

Waivers – providers

Disclosure of Ownership and Control Interest of an Entity, DHS-5259
Electronic Funds Transfer Vendor Number Notification, DHS-3725 (PDF)
HCBS – Provider Enrollment Application, DHS-4015 (PDF)
HCBS Programs Service Request Form, DHS-6638 (PDF)
MHCP Provider Agreement, DHS-4138 (PDF)
MinnesotaHelp.info Instructional Guide, DHS-6933 (PDF)
Notice of Temporary Service Suspension, DHS-2828C (PDF)
Notice of Service Termination, DHS-2828D (PDF)

Miscellaneous

Civil Rights Complaint Form: Discrimination in Service Delivery, DHS-2807 (PDF)
Maltreatment of Minors and Licensing Violations Report Form, DHS-4293 (PDF)
Medical Assistance for Employed Persons with Disabilities (MA-EPD) Initial Premium Notice, DHS-3547 (PDF)
MHCP Hospice Transaction Form, DHS-2868 (PDF)
Mobility Device Authorization Form, DHS-4315 (PDF)
Notice of Summary Disposition – Abuse /Neglect Did Not Occur; Protective Services Not Needed, DHS-4587 (PDF)
Psychotropic Medication Use Checklist, DHS-4254 (PDF)