Moving Home Minnesota (MHM) documents and forms

Page updated: 7/11/24

This page provides a list of frequently used MHM forms referenced in this manual. Use DHS – eDocs searchable document library to search for and download forms, applications and other documents.

Documents

MHM Money Follows the Person Demonstration Participant Handbook, DHS-6580B (PDF)

MHM Brochure, DHS-6580A (PDF)

Forms for people who receive services, lead agencies and transition coordinators

MHM Intake Form, DHS-5032:

· Completed for people who are interested in receiving MHM (can be completed by anyone)

· Starts the process for receiving MHM

MHM Informed Consent, DHS-6759I (PDF):

· Completed by people who are interested in receiving MHM

· Gives service providers, lead agencies and/or transition coordinators permission to gather personal information to determine program eligibility

MHM Communication Form, DHS-6759H:

· Completed by providers, transition coordinators and lead agencies

· Allows providers and case managers to communicate a person’s needs and changes to DHS, including when a person moves, returns to an institution or chooses to disenroll from MHM

· Allows providers to confirm a qualified community residence

· Allows providers to request an extension for transition coordination services

· Allows providers to submit documentation securely to DHS

· Allows providers to request assistance with denied claims for transition coordination beyond 180 days, relocation service coordination targeted case management (RSC-TCM) and MHM in the same month and the transition planning tool

MHM Transition Planning Tool, DHS-6759J:

· Completed by people who currently receive MHM and their transition coordinators

· Helps transition coordinators develop person-centered transition plans for moves to the community

MHM Transition Planning Tool Part 2: Risk Mitigation and Emergency Backup Planning, DHS-6759K

· Completed by people who currently receive MHM and their transition coordinators

· Helps transition coordinators address risks when no other risk mitigation tool exists

MHM Housing Transitions Worksheet, DHS-6759G:

· Completed by transition coordinators

· Helps determine the best type of housing for people applying for MHM

MHM Substance Use Disorder (SUD) Referral Form, DHS-6759N:

· Completed by licensed alcohol and drug counselors (LADCs)

· Allows LADCs to communicate people’s needs directly to transition coordinators

Professional Statement of Need, DHS-7122 (PDF)

· Completed by LADCs

· Establishes eligibility for people residing in a qualifying institution that meets the requirements on MHM Manual – Guide for MHM access and SUD

Forms for provider enrollment

Home and Community-Based Services (HCBS) Programs Service Request, DHS-6638 (PDF):

· Completed by providers at enrollment

· Identifies which services providers will deliver and determines the verifications needed for enrollment

MHM – Transition Planning, Transition Coordination and Demonstration Case Management – Provider Assurance Statement, DHS-3879 (PDF):

· Completed by providers at enrollment

· Documents that providers assure they meet the qualifications necessary to provide MHM