Minnesota Department of Human Services Forms

This Form is used for providers of Home and Community-Based Services (HCBS) in Minnesota to provide assurance of meeting the requirements set by the Minnesota Health Care Programs (MHCP).

This Form is used for substance use disorder (SUD) providers in Minnesota to provide assurance and comply with the Minnesota Health Care Programs (MHCP) guidelines for counties and tribes.

This form is used by customized living providers in Minnesota to provide assurance regarding their compliance with the Minnesota Health Care Programs (MHCP) requirements.

This form is used for Overnight Assistance providers in Minnesota Health Care Programs to provide an assurance statement.

This Form is used for Minnesota Health Care Programs (MHCP) housing consultation providers to provide assurance statements for the services they offer.

This form is used for provider enrollment application for Billing Intermediaries, Clearinghouses, and EDI Trading Partners in the Minnesota Health Care Programs (MHCP) in Minnesota.

This form is used for Eidbi provider agencies in Minnesota to provide assurance statement for the Minnesota Health Care Programs.

This form is used for Minnesota health care providers to enroll in the Minnesota Health Care Programs (MHCP) and become a direct care and treatment organization. It is the application process for providers to be able to participate in MHCP and provide services to eligible individuals in Minnesota.

This form is used for provider enrollment in the Minnesota Health Care Programs (MHCP) in Minnesota.

This document is used for applying to become a Health Care Case Coordinator and enroll in the Minnesota Health Care Programs.

This form is used for enrolling as an Individual Direct Support Worker in Minnesota Health Care Programs for Consumer Directed Community Supports (CDCs) and Consumer Support Grant (CSG).

This document is used for assigning payment for day training and habilitation services under the Minnesota Health Care Programs (MHCP) in Minnesota.

This form is used to apply for enrollment as a housing stabilization services provider for the Minnesota Health Care Programs (MHCP) in Minnesota.

This document is used for Minnesota Health Care Programs (MHCP) to provide an assurance statement for Adult Companion Services or Individualized Home Supports without training provider.

This form is used for submitting an assurance statement for Independent Living Skills Therapy Provider regarding Minnesota Health Care Programs in Minnesota.

This form is used for requesting a hardship exemption for Minnesota Health Care Programs (MHCP). It is specifically for residents of Minnesota who are facing financial difficulties and need assistance with their healthcare expenses.

This form is used for designating a billing person for home and community-based services waiver or alternative care in Minnesota Health Care Programs (MHCP). It is necessary for managing billing and financial aspects of these services.

This form is used for Lead Agencies in Minnesota Health Care Programs to provide assurance statements for the review and approval of HCBS (Home and Community-Based Services) providers.

This form is used for the Community First Services and Supports (CFSS) Assurance Statement for Consultation Services Lead Employee in Minnesota Health Care Programs (MHCP). It is required for individuals providing consultation services under the CFSS program.

This Form is used for Positive Supports Provider Assurance Statement in Minnesota Health Care Programs (MHCP) in Minnesota.

This form is used for adding additional information to a provider entity sale or transfer in the Minnesota Health Care Programs (MHCP).

This form is used for respite providers with a 245d or 144a license who are providing services in an unlicensed setting under the Minnesota Health Care Programs (MHCP). It includes an assurance statement.

This form is used for providers of specialized equipment and supplies to assure compliance with Minnesota Health Care Programs (MHCP) in Minnesota.

This document is used for monitoring food banks in Minnesota that participate in the TEFAP program. It helps ensure compliance and track the distribution of food to those in need.

This Form is used for monitoring the distribution of emergency food assistance through the TEFAP program in Minnesota.

This Form is used for transferring emergency food assistance through the TEFAP program in Minnesota.

This form is used for reporting monthly adjustments to the TEFAP program in the state of Minnesota.

This document is used for reporting incidents related to the Emergency Food Assistance Program (TEFAP) in Minnesota.

This form is used for assessing adult disability in the state of Minnesota by the State Medical Review Team (SMRT).