Form DHS-7176A-ENG "Hcbs Provider Attestation Hardship Extension Request" - Minnesota

What Is Form DHS-7176A-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Minnesota Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHS-7176A-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-7176A-ENG "Hcbs Provider Attestation Hardship Extension Request" - Minnesota

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Clear Form
*DHS-7176A-ENG*
DHS-7176A-ENG
3-17
HOME AND COMMUNITY-BASED SERVICES (HCBS)
Provider Attestation Hardship Extension Request
Providers use this form to request an extension when they believe they will not be in compliance by Sept. 1, 2017, with
HCBS requirements (as outlined in the
provider attestation form,
DHS-7176).
DHS only will approve extensions due to provider hardship, including (but not limited to) time needed to operationalize
or board/legal approval needed. You will hear from DHS about the status of your extension request after Sept. 1, 2017.
If you have questions about this form, contact hcbs.settings@state.mn.us.
Instructions
To make an initial request
If you need to request an extension for items on the attestation form, complete the following (attach extra pages if you
need more room for answers):
1. Click applicable checkbox(s) on this form for
7. Select “add file”
each standard you request an extension for
8. Click “browse”
2. Enter the action steps/timeline each setting
9. Navigate to where you saved this document
will take to fully comply
10. Select the file
3. Save a copy of this form (you can delete the pages of
11. Select “finish”
categories you don’t use, if you like)
12. Assign this document as “extension form” in the
4. Open the
attestation form (DHS-7176)
drop-down list in the documents table
5. Navigate to the last page
13. Submit the attestation (after you upload
6. Select “attach required documents”
attachments).
To complete process after making changes
After you make changes to the setting and it complies:
1. Open the
attestation form (DHS-7176)
5. Change applicable areas marked as “additional time
needed/ hardship extension requested”
2. Select “update a submitted attestation”
6. Attach supporting documentation for area(s) changed
3. Enter your license or HFID number
to comply
4. Enter your email number
7. Select “submit attestation.”
Settings not eligible
Please note that the following categories of settings are not eligible for an extension:
15 and 16. Settings identified as in or adjacent to an institution
17. Settings identified as a farmstead/disability farm community, residential school or a gated community for people
with disabilities.
Your information
(must match information on attestation form exactly)
PROVIDER AGENCY
LICENSING NUMBER OR HFID NUMBER
CONTACT NAME
CONTACT PHONE NUMBER
CONTACT EMAIL ADDRESS
Page 1 of 2
Clear Form
*DHS-7176A-ENG*
DHS-7176A-ENG
3-17
HOME AND COMMUNITY-BASED SERVICES (HCBS)
Provider Attestation Hardship Extension Request
Providers use this form to request an extension when they believe they will not be in compliance by Sept. 1, 2017, with
HCBS requirements (as outlined in the
provider attestation form,
DHS-7176).
DHS only will approve extensions due to provider hardship, including (but not limited to) time needed to operationalize
or board/legal approval needed. You will hear from DHS about the status of your extension request after Sept. 1, 2017.
If you have questions about this form, contact hcbs.settings@state.mn.us.
Instructions
To make an initial request
If you need to request an extension for items on the attestation form, complete the following (attach extra pages if you
need more room for answers):
1. Click applicable checkbox(s) on this form for
7. Select “add file”
each standard you request an extension for
8. Click “browse”
2. Enter the action steps/timeline each setting
9. Navigate to where you saved this document
will take to fully comply
10. Select the file
3. Save a copy of this form (you can delete the pages of
11. Select “finish”
categories you don’t use, if you like)
12. Assign this document as “extension form” in the
4. Open the
attestation form (DHS-7176)
drop-down list in the documents table
5. Navigate to the last page
13. Submit the attestation (after you upload
6. Select “attach required documents”
attachments).
To complete process after making changes
After you make changes to the setting and it complies:
1. Open the
attestation form (DHS-7176)
5. Change applicable areas marked as “additional time
needed/ hardship extension requested”
2. Select “update a submitted attestation”
6. Attach supporting documentation for area(s) changed
3. Enter your license or HFID number
to comply
4. Enter your email number
7. Select “submit attestation.”
Settings not eligible
Please note that the following categories of settings are not eligible for an extension:
15 and 16. Settings identified as in or adjacent to an institution
17. Settings identified as a farmstead/disability farm community, residential school or a gated community for people
with disabilities.
Your information
(must match information on attestation form exactly)
PROVIDER AGENCY
LICENSING NUMBER OR HFID NUMBER
CONTACT NAME
CONTACT PHONE NUMBER
CONTACT EMAIL ADDRESS
Page 1 of 2
Categories
Residential
1. Each person at the setting has a written lease or residency agreement in place providing
protections to address eviction processes and appeals.
Why do you need an extension? Please explain your reason (e.g., need time to operationalize, need management board, legal
approval, etc.)
What action steps do you need to take to comply with this requirement?
What have you already done to reach compliance before the Sept. 1, 2017 deadline?
Date you will be in full compliance with this requirement (must be no later than 12/31/17)
Page 2 of 18
DHS-7176A-ENG 3-17
2. Each person at the setting has privacy in his/her sleeping or living unit including a lockable
bedroom or front door.
Why do you need an extension? Please explain your reason (e.g., need time to operationalize, need management board, legal
approval, etc.)
What action steps do you need to take to comply with this requirement?
What have you already done to reach compliance before the Sept. 1, 2017 deadline?
Date you will be in full compliance with this requirement (must be no later than Dec. 31, 2017)
Page 3 of 18
DHS-7176A-ENG 3-17
3. The setting facilitates that a person, who shares a bedroom, is with a roommate of
his/her choice.
Why do you need an extension? Please explain your reason (e.g., need time to operationalize, need management board, legal
approval, etc.)
What action steps do you need to take to comply with this requirement?
What have you already done to reach compliance before the Sept. 1, 2017 deadline?
Date you will be in full compliance with this requirement (must be no later than Dec. 31, 2017)
Page 4 of 18
DHS-7176A-ENG 3-17
4. The setting provides people with the freedom to furnish and decorate their bedroom and
living unit within the terms of the lease or residency agreement.
Why do you need an extension? Please explain your reason (e.g., need time to operationalize, need management board, legal
approval, etc.).
What action steps do you need to take to comply with this requirement?
What have you already done to reach compliance before the Sept. 1, 2017 deadline?
Date you will be in full compliance with this requirement (must be no later than Dec. 31, 2017)
Page 5 of 18
DHS-7176A-ENG 3-17
Page of 18