CFSS forms and documents
Page updated: 9/16/24
DHS is working to post new forms and documents for CFSS. We will update existing PCA forms that require minor changes on a rolling basis throughout the year.
To find a form or document, use DHS – Searchable document library (eDocs) and search by the number.
Published forms and documents
CFSS Home Care Rating/Units Reference Tool, DHS-6893H (PDF)
CFSS Individual Service Delivery Plan, DHS-6893P
Note: DHS is aware of a bug in the agency/goods and services table on DHS-6893P and is working to correct it.
CFSS Rights and Responsibilities, DHS-6893R (PDF)
Forms that need updates based on public comments
CFSS Consultation Services Session Documentation, DHS-6893S
Worker Information for CFSS Budget Model, DHS-6893T
Unpublished forms
DHS is still completing work on the following CFSS forms. We will add links when they are available.
New CFSS forms
45-day Temporary Increase Assessment, DHS-6893M
45-day Temporary Start Service Delivery Plan, DHS-6893Q
Recommendation for Removal from the CFSS Budget Model, DHS-6893D
New CFSS versions of PCA forms
Updated replacement | Old form |
CFSS Assessment, DHS-6893A | |
Referral for Reassessment for PCA/CFSS Services, DHS-6893B | |
CFSS Worker Time and Activity Documentation, DHS-6893C | PCA Worker Time and Activity Documentation, DHS-4691 (PDF) Note: DHS-4691 will remain available during the transition to CFSS |
Home Care Shared Services Agreement (HCN, PCA or CFSS), DHS-6893E | Home Care Shared Services Agreement (HCN or PCA), DHS-5899 (PDF) |
PCA Program Responsible Party Form/CFSS Participant Representative Agreement, DHS-6893F |
Current PCA forms to use until new CFSS forms are available
PCA Lead Agency Request Form, DHS-4292 (will be replaced with CFSS Lead Agency Request Form, DHS-6893I)
PCA Technical Change Request, DHS-4074A (will be replaced with CFSS Technical Change Request, DHS-6893K)
Retired forms
PCA Communication to Physician of PCA Services, DHS-4690 is no longer required in CFSS.
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