WebDec 8, 2024 · Submit Forms via Fax. Complete the following documents for each location providing services and fax the materials to MHCP at 651-431-7493. HCBS Programs Service Request (DHS-6638) to report the service (s) requested to provide and to determine the qualifications needed to provide those service (s). http://hcopub.dhs.state.mn.us/epm/2_4_1.htm
2.4.1 MA-LTC Eligibility Requirements - hcopub.dhs.state.mn.us
WebFollow the step-by-step instructions below to design your form dhs 3876 form: Select the document you want to sign and click Upload. Choose My Signature. Decide on what kind of signature to create. There are three variants; a typed, drawn or uploaded signature. Create your signature and click Ok. WebApplication forms. DHS-3531-ENG: Minnesota Health Care programs applications for payment of long-term care services; DHS-3876-ENG: Minnesota Health Care programs application for certain populations; DHS-5223: Combined application form; Authorized representative form. DHS-3437-ENG: Giving permission for someone to act on my … literature list of books
FORMS USED TO REQUEST MA-LTC - Minnesota
WebJan 29, 2024 · DHS-7418 Host County Notification of Residential Placement Form (PDF) DHS-7759A Remote Support Exception Form. DHS-7759B Customized Living Size-Limit Exception Request Form. DHS-7759E Safety Checklist for Out-of-Home Respite Services in an Unlicensed Setting (PDF) DHS-8062 Setting Capacity Report. WebJun 1, 2024 · The Minnesota MA Application/Renewal Breast and Cervical Cancer form is for people who were screened by the Sage Screening Program and have breast or cervical cancer and are seeking MA coverage. ... Applicants must submit DHS-3443 with a completed application; a DHS-6696, DHS-3876, DHS-5038 or DHS-3531. Applicants … WebFeb 28, 2024 · Call the Dakota County METS Health Care Team at 651-554-6696 or visit MNSure's Find Free Help page. to access a list of assisters, brokers and navigators near you. ... Download the Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS 3531). Applying for health care can be confusing, and we are … import contacts into outlook live