Minnesota Department of Human Services Forms

This Form is used for applying for Title IV-E Foster Care in the state of Minnesota.

This form is used for conducting a quality checklist for the functional behavior assessment in Minnesota. It helps ensure that the assessment is conducted effectively and produces accurate results.

This form is used for requesting authorization to use emergency procedures in the state of Minnesota.

This form is used for creating a safety plan to protect youth from exploitation or trafficking in Minnesota.

This Form is used for the review of a Positive Support Transition Plan in Minnesota.

This checklist is used for conducting a post-intervention debriefing in the state of Minnesota.

This document is a checklist used in Minnesota to ensure the quality of a transition plan for individuals with disabilities.

This form is used for notifying the Minnesota Department of Human Services about the Electronic Funds Transfer (EFT) vendor number for a provider.

This form is used for reporting other health insurance information in Minnesota.

This form is used for disclosing the ownership and control interests of an entity in the state of Minnesota.

This form is used for obtaining authorization in Minnesota for Ctss services.

This form is used for MHCP authorization in the state of Minnesota. It is used to request authorization for various services covered by Minnesota Health Care Programs (MHCP).

This Form is used for physician certification in the state of Minnesota. It is used to certify the medical condition of an individual for specific purposes.

This Form is used for requesting authorization for enteral/nutritional services in the state of Minnesota. It ensures that individuals receive the necessary nutrition support they require.

This Form is used for obtaining authorization for specialized wound therapy in the state of Minnesota. It is a necessary document for individuals seeking this type of medical treatment.

This form is used for obtaining authorization for standards and accessories related to DHS-4075-ENG in the state of Minnesota.

This form is used for obtaining authorization for augmentative communication devices and accessories in the state of Minnesota.

This Form is used for authorizing prosthetics and orthotics in the state of Minnesota.

This Form is used for obtaining authorization for bath/shower/toileting equipment in Minnesota.

This form is used for hospice transactions in the state of Minnesota.

This Form is used for the Ground Ambulance Billing Checklist in the state of Minnesota. It helps ensure that all necessary information is included for billing purposes.

This form is used for documenting Individualized Education Plan (IEP) and Individualized Family Service Plan (IFSP) services in Minnesota.

This document is used for keeping track and documenting the evaluation process for Individualized Education Plans and Individualized Family Service Plans in Minnesota.

This document is used for recording and tracking IEP/IFSP services in Minnesota. It helps document the services provided to individuals with disabilities as part of their individualized education or family service plans.

This form is used for notifying the intent to bill for mental health evaluations related to Individual Education Plans (IEP) in Minnesota.

This form is used for reporting annual data on Individualized Education Program (IEP) services in Minnesota.

This form is used for giving someone permission to act on your behalf in Minnesota.

This document is used for requesting a reconsideration of a prescription drug in Minnesota.

This form is used for submitting research requests to the Minnesota Department of Homeland Security.

This form is used for requesting a psychiatric consultation in the state of Minnesota.

This form is used for requesting prior authorization for high dose opioid drugs in the state of Minnesota.

This form is used for submitting a prior authorization request for Hepatitis C drugs in the state of Minnesota.

This type of document is an integrated relapse prevention plan for individuals with co-occurring disorders in the state of Minnesota. It includes strategies and resources to help prevent relapse and maintain recovery for individuals with mental health and substance use disorders.

This document is used for the evaluative report required for the Level II Preadmission Screening (PAS) process for individuals with mental illness in Minnesota.

This form is used for Children's Therapeutic Services and Supports (CTSS) providers in Minnesota to provide assurance statements.

This Form is used for applying for primary certification as a crisis response service provider in Minnesota.