CFSS forms and documents
Page updated: 11/6/24
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
New/updated document | Notes |
DHS-6893A replaced: Make sure to use the 10-24 version. | |
This resource page replaced PCA Assessment and Service Plan Instructions and Guidelines, DHS-3244A | |
CFSS Program Information and Signature Sheet, DHS-6893G (PDF) | DHS-6893G replaced LTSS Assessment and Program Information and Signature Sheet, DHS-2727, which was a form previously used for MnCHOICES. |
This form is new for CFSS. Make sure to use the 11-24 version. | |
DHS-6893H replaced Personal Care Assistance (PCA) Decision Tree, DHS-4201. | |
CFSS Rights and Responsibilities, DHS-6893R-ENG (PDF) or translations: | Providers and lead agencies use this form instead of the Home Care Bill of Rights (PDF). Note: DHS is working to post Hmong and Karen translations. |
CFSS Information Sheet – English, DHS-8477A-ENG (PDF) or translations: | This document is a new one-page fact sheet with general information about CFSS. |
DHS-6893B replaced Referral for Reassessment for PCA Services, DHS-3244P. | |
PCA Program Responsible Party Form/CFSS Participant Representative Agreement, DHS-6893F | DHS-6893F replaced PCA Program Responsible Party Form, DHS-5856. |
CFSS Consultation Services Session Documentation, DHS-6893S (PDF) | This form is new for CFSS. |
This form is new for CFSS. | |
Recommendation for Removal from the CFSS Budget Model, DHS-6893D (PDF) | This form is new for CFSS. |
Home Care Shared Services Agreement (HCN, PCA or CFSS), DHS-6893E (PDF) | DHS-6893E replaced Home Care Shared Services Agreement (HCN or PCA), DHS-5899. |
Consultation Services Provider CFSS Service Delivery Plan Cover Sheet, DHS-6893N | This form is new for CFSS. |
Unpublished forms
DHS is completing work on the following CFSS forms. We will add links when they are available.
New/updated form not published yet | Notes |
CFSS Worker Time and Activity Documentation, DHS-6893C | Use PCA Worker Time and Activity Documentation, DHS-4691 (PDF) until the CFSS version is ready. DHS-4691 will remain available during the transition to CFSS. |
CFSS Lead Agency Request Form, DHS-6893I | Use PCA Request Form, DHS-4292 for both CFSS and PCA requests until DHS publishes the new form. DHS will update Instructions to complete the PCA Request Form, DHS-4292A (PDF) with instructions to submit CFSS-related requests with DHS-4292. |
CFSS Technical Change Request, DHS-6893K | Use PCA Technical Change Request, DHS-4074A for both CFSS and PCA until DHS publishes the new form. DHS will update Instructions to complete PCA Technical Change Request Form, DHS-4074C (PDF) with instructions to submit CFSS-related requests with DHS-4074A. |
CFSS 45-Day Temporary Increase Assessment, DHS-6893M | This will be a new form. Lead agencies must use CFSS Assessment, DHS-6893A until DHS posts DHS-6893M. |
CFSS 45-Day Temporary Start Service Delivery Plan, DHS-6893Q | This will be a new form. Provider agencies must use CFSS Individual Service Delivery Plan, DHS-6893P until DHS posts DHS-6893Q. |
Retired forms
PCA Communication to Physician of PCA Services, DHS-4690 is no longer required in CFSS.
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