ICF/DD Forms

A DHS eDocs database allows you to search for and download additional DHS forms, applications and other documents in 10 languages (refer to information on Documents and written materials in other languages).

Billing and MMIS-related forms	General forms	ICF/DD specific forms
Miscellaneous forms	Screening forms
Billing and MMIS-related forms				Back to Top
Day Training and Habilitation Service Agreement DHS-2638 (PDF) MHCP Individual Practitioner – Provider Enrollment Application DHS-4016 (PDF) MHCP Organization – Provider Enrollment Application DHS-4016A (PDF)
General forms					Back to Top
Appeal to State Agency DHS-0033 (PDF) | Instructions to Appeal to State Agency DHS-0033A (PDF) Health Care Application Inter-Agency Transfer Form DHS-3195 (PDF) Maltreatment/Licensing Report Form DHS-4293 (PDF) State Agency Appeals Summary DHS-0035 (PDF) Variance Request DHS-3141 (PDF)
ICF/DD specific forms					Back to Top
Extended Therapeutic Days Application DHS-4677E (PDF) Income and Expense Report (Excel fillable version) (PDF) Local System Needs Plan Amendment DHS-4677C (PDF) Occupancy Report (PDF) Physician Recertification DHS-1743 (PDF) Proposal of Changes to an ICF/DD DHS-4677H (PDF) (Closure, downsizing and/or relocation) Provider Application for 186 Special Needs Funding DHS-4677D (PDF) Services During the Day Option Agreement DHS-4677G (PDF) Services During the Day Option Application DHS-4677F (PDF) Variable Rate Recommendation Form and Instructions DHS-4677A (PDF) Variable Rate Quarterly Reporting Form and Instructions DHS-4677B (PDF)
Miscellaneous forms			Back to Top
Authorization Request for Wheelchairs, Scooters and Accessories DHS-4315 (PDF) Civil Rights Complaint Form: Discrimination in Service Delivery DHS-2807 (PDF) Death and Serious Injury Reporting Targeted Case Management (TCM) Data Transmittal Form DHS-3152 (PDF) - Obsolete
Screening forms			Back to Top
Case Manager’s Guide to Determining ICF/DD Level of Care for ICF/DD and DD Waiver Services DHS-4147A (PDF) | Instructions for CMs Guide to Determining ICF/DD and DD Waiver DHS-4147B (PDF) DD Screening Document DHS-3067 (PDF) Evaluative Report: Level II Preadmission Screening for Persons with Developmental Disabilities or Related Conditions DHS-4248 (PDF) Instructions for Completing and Entering the LTC Screening Document and Service Agreement into MMIS Physician Certification DHS-1503 (PDF) Pre-Admission Screening and Assessment (PAS) Program Level 1: Screening for Mental Illness or Developmental Disability DHS-3426 (PDF) Related Conditions Checklist/Instructions DHS-3848 (PDF) | Instructions Related Conditions Checklist DHS-3848A (PDF)