A to Z of DSD forms
A | B | C | D | E | H | I | L | M | N | O | P | R | S | V | W
Note: For information about forms required for long-term services and supports (LTSS), refer to CBSM – Forms for LTSS assessment, eligibility and support planning.
A
AC, BI, CADI and EW Case Mix Classification Worksheet, DHS-3428B (PDF)
Additional Square Footage Checklist, DHS-5887 (PDF)
Affected Participant Consent for the Use of Monitoring Technology, DHS-6789C (PDF)
Annual Review of Ward under Public Guardianship, DHS-5836
Appeal to State Agency, DHS-0033
DSD Application for Emergency Disaster Assistance (PDF)
Authorization Request for Mobility Devices, DHS-4315 (PDF)
B
Behavior Intervention Reporting Form (BIRF), DHS-5148 and Instructions, DHS-5148A (PDF)
BI Waiver Assessment and Eligibility Determination DHS-3471 (PDF)
BI Waiver Assessment and Eligibility Determination Instructions/Worksheet DHS-3471A (PDF)
BI Waiver Assessment and Eligibility Determination Checklist DHS-3471B (PDF)
C
Caregiver Living Expenses Worksheet, DHS-4929 (PDF)
Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services, DHS-4147A (PDF)
Completing the Case Managers Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147B (PDF)
CDCS Alternative Treatment Form for MHCP-Enrolled Physicians, DHS-5788 (PDF)
CDCS Community Support Plan Addendum, DHS-6633A (PDF)
CFSS/PCA Request Form, DHS-4292
Civil Rights Complaint Form: Discrimination in Service Delivery, DHS-2807 (PDF)
County of Financial Responsibility Transfer for FSG, DHS-4007 (PDF)
County Parental Fee Referral to DHS, DHS-2982
Customized Living Size-Limit Exception Request Form, DHS-7759B
D
Day Services Determination of Need Application to Expand, DHS-4960A (PDF)
Day Services Determination of Need Application for Proprietary Changes, Reductions and Closures, DHS-4960B (PDF)
Day Training and Habilitation Service Agreement DHS-2638 (PDF)
DD Waiver Waiting List Category Determination Tool, DHS-7209 (PDF)
DD Screening Document, DHS-3067
Disability Waiver Rates System Exception Request Application, DHS-5820 and Instructions, DHS-5820A (PDF)
DSD Contact Form, DHS-8168
E
EIDBI Advisory Group Agenda Submission Form, DHS-3807 (PDF)
EIDBI Authorization Request, DHS-3806 and Instructions, DHS-3806A (PDF)
Exception to CDCS Budget Methodology, DHS-6633
Exception Request for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD waivers), DHS-5504B (PDF)
Exception Request Checklist for Environmental Accessibility Adaptations that Exceed $40,000 (CAC, CADI, BI and DD waivers), DHS-5504C (PDF)
H
HCBS Provider Attestation, DHS-7176
HCBS Rights Modification Support Plan Attachment, DHS-7176H
Home Care Nursing (HCN) Hardship Waiver Application, DHS-4109 (PDF)
Home Care Nursing Service Decision Tree, DHS-4071C (PDF)
Host County Notification of Residential Placement Form, DHS-7418 (PDF)
I
ICF/DD Local System Needs Plan Amendment, DHS-4677C (PDF)
Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS, DHS-4625 (PDF)
Instructions for Completing and Entering the LTCC Screening Document into MMIS for the MSHO and MSC+ Programs, DHS-4669 (PDF)
Instructions for Completing and Entering the LTCC Screening Document into MMIS for SNBC, DHS-5020A (PDF)
Inter Agency Case Transfer Form, DHS-3195 (PDF)
L
Lead Agency Assurance Statement: HCBS Provider Review and Approval, DHS-6383 (PDF)
LTC Screening Document - AC, BI, CAC, CADI, ECS, EW, MHM, MSC+, MSHO, SNBC DHS-3427 (PDF)
LTC Screening Document - Telephone Screening DHS-3427T (PDF)
M
MA Home Care Technical Change Request, DHS-4074
MA Home Care Nursing Assessment, DHS-4071A (PDF)
MA Home Care Nursing Assessment Instructions, DHS-4071B (PDF)
Maltreatment of Minors and Licensing Violations Report Form, DHS-4293 (PDF)
Managed Care Organization/County/Tribal Agency Communication Form – Recommendation for State Plan Home Care Services, DHS-5841
Medical Assistance for Employed Persons with Disabilities (MA-EPD) Initial Premium Notice, DHS-3547 (PDF)
Medical Assistance Parental Fee Form, DHS-2981 (PDF)
Minnesota Health Care Programs Hospice Transaction Form, DHS-2868 (PDF)
Minnesota Health Care Programs Provider Enrollment Application, DHS-4016
MinnesotaHelp.info Instructional Guide, DHS-6933 (PDF)
MHCP Organization Provider Enrollment Application, DHS-4016A (PDF)
MnCHOICES Case Manager's Recipient Information Form, DHS-7185
MnCHOICES Community Support Plan Worksheet, DHS-6791A (PDF)
MnCHOICES Community Support Plan with the Coordinated Services and Supports Plan DHS-6791B and Instructions, DHS-6791B (PDF)
MnCHOICES Help Desk Contact Form, DHS-6979
MnCHOICES Reassessment Communication Form, DHS-6791E and Instructions, DHS-6791F (PDF)
Monitoring Technology Approval Request, DHS-6789A
Moving Home Minnesota Communication Form, DHS-6759H
Moving Home Minnesota Informed Consent, DHS-6759I (PDF)
Moving Home Minnesota Housing Transitions Worksheet, DHS-6759G
N
Notice of Action (Assessments and Reassessments), DHS-2828A
Notice of Action (Support Plan), DHS-2828B
O
OBRA Level I Criteria Screening for Developmental Disabilities or Mental Illness, DHS-3426
OBRA Level II Evaluative Report, DHS-4248
P
Participant Consent for the Use of Monitoring Technology, DHS-6789B (PDF)
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)
R
Related Conditions Checklist, DHS-3848 (PDF)
Related Conditions Checklist Instructions, DHS-3848A (PDF)
Remote Support Exception Form, DHS-7759A
Request for the Authorization of the Emergency Use of Procedures, DHS-6810D
Request for Medicaid Administrative Reimbursement or Reimbursement for Alternative Care, DHS-5504
Request for Payment of Long-Term Care Services DHS-3543 (PDF)
Request to Close or Develop New Corporate Foster Care and Community Residential Settings, DHS-6021
RMS Worksheet for Community Residential Services or Family Residential Services, DHS-6790C (PDF)
RMS Worksheet for Customized Living and 24-Hour Customized Living, DHS-6790G
RMS Worksheet for Day and Employment Services, DHS-6790M
RMS Worksheet for Integrated Community Supports, DHS-6790O (PDF)
S
Safety Checklist for Out-of-Home Respite Services in an Unlicensed Setting, DHS-7759E (PDF)
Service Agreement, DHS-3070 (PDF)
Setting Capacity Report, DHS-8062
State Agency Appeals Summary, DHS-0035 (PDF)
V
Variance Request, DHS-3141 (PDF)
Voluntary Closure Application: Corporate Adult Foster Care/Community Residential Setting Planned Closure, DHS-6021B
W
Waiver and Alternative Care (AC) Programs Provider Enrollment Application, DHS-4015 (PDF)
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