SFN | Title | Size | Date | Fillable |
3
|
EBT SECOND PARTY REVIEW REPORT
|
346 kb
|
12/11/2012
|
Y
|
9
|
MEDICAID REHAB SERVICES PROVIDER ENROLLMENT ATTESTATION
|
938 kb
|
09/29/2020
|
Y
|
11
|
EMERGENCY ASSISTANCE ACTION PLAN
|
208 kb
|
|
N
|
20
|
SUSPECTED FRAUD REFERRAL
|
534 kb
|
09/07/2017
|
Y
|
21
|
TRANSMITTED BETWEEN UNITS
|
506 kb
|
09/14/2011
|
Y
|
23
|
APPLICATION FOR APPROVAL FOR RELATIVE CHILD CARE PROVIDER
|
670 kb
|
08/26/2019
|
Y
|
29
|
CROSSROADS PROGRAM APPLICATION
|
468 kb
|
10/31/2014
|
Y
|
38
|
EMERGENCY ASSISTANCE SERVICE APPLICATION
|
233 kb
|
06/12/2014
|
Y
|
42
|
PRINTING REQUEST
|
831 kb
|
10/20/2020
|
Y
|
44
|
COMPOSING SERVICES REQUEST
|
812 kb
|
10/20/2020
|
Y
|
45
|
NOTICE OF CHANGE
|
837 kb
|
10/27/2020
|
Y
|
49
|
CHILD CARE ASSISTANCE PROGRAM DIRECT DEPOSIT BANKING INFO
|
1079 kb
|
02/10/2016
|
Y
|
51
|
AUTHORIZATION FOR COUNTY EMPLOYEE TRAVEL REIMBURSEMENT
|
821 kb
|
03/01/2010
|
Y
|
56
|
EXSPED PROGRAM DATA
|
1325 kb
|
12/03/2019
|
Y
|
60
|
18+ CONTINUED FOSTER CARE AGREEMENT
|
397 kb
|
08/30/2019
|
Y
|
61
|
HEALTH TRACKS COMPREHENSIVE ORTHODONTIC SCREENING
|
509 kb
|
08/25/2020
|
Y
|
62
|
EMERGENCY ASSISTANCE APPLICATION
|
326 kb
|
|
Y
|
65
|
DAILY REMITTANCE LIST
|
1273 kb
|
02/11/2020
|
Y
|
75
|
MISCELLANEOUS PAYMENT WORKSHEET
|
279 kb
|
07/07/2017
|
Y
|
76
|
FIXED ASSET CHANGE REQUEST
|
361 kb
|
11/04/2008
|
Y
|
78
|
REQUEST FOR PURCHASE
|
532 kb
|
11/26/2018
|
Y
|
79
|
SUBSTANCE USE DISORDER SERVICE AUTHORIZATION REQUEST
|
563 kb
|
10/29/2020
|
Y
|
81
|
DESIGNATED MEDICAL PROVIDER
|
921 kb
|
03/18/2019
|
Y
|
91
|
REVOCATION OF AUTHORIZATION TO DISCLOSE INFORMATION
|
340 kb
|
09/30/2013
|
Y
|
94
|
SECURITY REQUEST FOR ACCESS TO DEVELOPMENTAL DISABILITIES SY
|
908 kb
|
06/22/2020
|
Y
|
96
|
CERTIFICATE OF MEDICAL NECESSITY-EXT INSULIN INFUSION PUMP
|
362 kb
|
01/19/2017
|
Y
|
98
|
CASE MANAGEMENT INTER-AGENCY REFERRAL
|
178 kb
|
|
Y
|
101
|
GRANT OPPORTUNITY - APPOVAL TO APPLY
|
367 kb
|
02/06/2012
|
Y
|
128
|
ND FAMILY CAREGIVER SUPPORT PROGRAM PROVIDER AGREEMENT
|
950 kb
|
10/28/2020
|
Y
|
132
|
PHYSICIAN STATEMENT FOR MEDICAID TEMPORARY STAY REVIEW
|
903 kb
|
01/29/2019
|
Y
|
136
|
PLAN OF CORRECTION HCBS SURVEY
|
1236 kb
|
10/16/2020
|
Y
|
143
|
CIVIL RIGHTS COMPLAINT
|
933 kb
|
11/02/2018
|
Y
|
150
|
60 MONTH LIFETIME EXEMPTION BACKGROUND REPORT
|
175 kb
|
|
Y
|
152
|
CHILD SUPPORT VERIFICATION
|
108 kb
|
|
Y
|
162
|
REQUEST FOR HEARING
|
911 kb
|
02/25/2020
|
Y
|
164
|
SUBRECIPIENT RISK ASSESSMENT CHECKLIST
|
800 kb
|
06/30/2017
|
Y
|
165
|
CAREGIVER OPTION PLAN-FAMILY CAREGIVER SUPPORT PROGRAM
|
1240 kb
|
11/02/2020
|
Y
|
170
|
TAXI TRANSPORTATION VOUCHER
|
265 kb
|
07/25/2017
|
Y
|
171
|
FOSTER PROGRAM SUBSIDIZED EMPLOYMENT AGREEMENT
|
247 kb
|
02/03/2010
|
Y
|
172
|
IN-HOME SUPPORT APPLICATION
|
2136 kb
|
10/16/2020
|
Y
|
173
|
SUBRECIPIENT RISK ASSESSMENT CHECKLIST-COUNTIES
|
816 kb
|
07/17/2017
|
Y
|
175
|
INDIVIDUAL REQUEST TO BE A QSP FOR RESPITE CARE
|
1438 kb
|
05/20/2019
|
Y
|
177
|
MMIS ATTACHMENT COVER SHEET
|
362 kb
|
08/31/2015
|
Y
|
180
|
APPLICATION FOR VOCATIONAL REHABILITATION SERVICES
|
598 kb
|
11/12/2019
|
Y
|
185
|
AWARE ND APPLICATION SUPPLEMENT
|
1370 kb
|
07/15/2020
|
Y
|
187
|
MEDICAL EXPENSE WORKSHEET
|
407 kb
|
08/09/2010
|
Y
|
196
|
ABILITY TO PAY - FEE ACTION REQUEST
|
525 kb
|
10/20/2016
|
Y
|
199
|
DISQUALIFYING TRANSFER WORKSHEET
|
504 kb
|
09/02/2014
|
Y
|
200
|
ASSET ASSESSMENT
|
1096 kb
|
09/08/2017
|
Y
|
202
|
GROUP HOME & DRUG/ALCOHOL TREATMENT CTRS MONTHLY LISTING
|
345 kb
|
10/08/2012
|
Y
|
206
|
STATUS TRACKING LOG
|
980 kb
|
12/27/2019
|
Y
|
208
|
CARD PROBLEM REPORT
|
419 kb
|
12/02/2013
|
Y
|
212
|
RURAL DIFFERENTIAL UNIT RATE AUTHORIZATION/CLOSURE
|
504 kb
|
01/31/2019
|
Y
|
225
|
NDFCSP RURAL DIFFERENTIAL UNIT RATE AUTHORIZATION
|
906 kb
|
12/30/2020
|
Y
|
228
|
WORKING DISABILITY REPORT
|
481 kb
|
09/08/2017
|
Y
|
229
|
ACTIVITY APPROVAL/PERMIT FOR DHS FACILITIES
|
636 kb
|
01/06/2017
|
Y
|
231
|
COORDINATED SERVICES PROGRAM (CSP) REFERRAL
|
315 kb
|
05/20/2019
|
Y
|
244
|
PURCHASE ORDER/PURCHASE CARD CONFIRMATION
|
288 kb
|
10/29/2009
|
Y
|
249
|
MEDICAL CERTIFICATE OF TRANSPORTATION SERVICES
|
327 kb
|
07/02/2019
|
Y
|
252
|
CHAFEE EDUCATION AND TRAINING VOUCHER PROGRAM (ETV)
|
885 kb
|
01/08/2019
|
Y
|
255
|
CHAFEE PROGRAM REQUEST FOR FINANCIAL ASSISTANCE
|
909 kb
|
01/07/2019
|
Y
|
270
|
REQUEST FOR REPLACEMENT DUE TO LOSS OF FOOD PURCHASED WITH S
|
341 kb
|
08/17/2012
|
Y
|
293
|
SNAP PROGRAM NEGATIVE CASE REVIEW
|
544 kb
|
12/03/2019
|
Y
|
294
|
NON-EMERGENCY MEDICAL TRANSPORTATION AUTHORIZATION
|
328 kb
|
07/01/2019
|
Y
|
296
|
NON-EMERGENCY MEDICAL TRANSPORTATION TRIP TICKET
|
595 kb
|
01/28/2019
|
Y
|
298
|
PROTECTIVE SERVICES ALERT
|
171 kb
|
|
Y
|
302
|
AUTHORIZATION & REQUEST FOR PAYMENT (DRUG/PHARMACY)
|
419 kb
|
11/29/2012
|
Y
|
307
|
REQUEST FOR SAFETY/PERMANENCY FUNDS
|
368 kb
|
06/12/2014
|
Y
|
319
|
MONTHLY EBT INVENTORY CONROL LOG
|
342 kb
|
08/09/2010
|
Y
|
321
|
DAILY CARD ISSUANCE LOG
|
396 kb
|
03/24/2011
|
N
|
323
|
JOBS STATUS CHANGE
|
158 kb
|
11/08/2012
|
Y
|
325
|
EBT CARD STOCK TRANSFER
|
279 kb
|
10/18/2010
|
Y
|
329
|
DIVERSION ASSISTANCE CHEATSHEET
|
296 kb
|
01/14/2008
|
Y
|
331
|
NDFCSP NOTICE OF SERVICE DENIAL OR CLOSURE
|
1056 kb
|
05/10/2017
|
Y
|
332
|
REQUEST FOR PROVIDER LISTING ON THE ADRL)
|
1286 kb
|
11/02/2020
|
Y
|
336
|
PRESCRIBER TRANSFER REQUEST
|
440 kb
|
08/21/2019
|
Y
|
337
|
SNAP CLAIM REVIEW
|
667 kb
|
11/21/2019
|
Y
|
338
|
CHILDCARE CHECKLIST
|
660 kb
|
04/22/2014
|
Y
|
339
|
MONTHLY CASE MGMT BILLING & REPORTING
|
359 kb
|
12/26/2007
|
Y
|
344
|
THERAPEUTIC PET OR SERVICE ANIMAL REQUEST
|
907 kb
|
11/08/2019
|
Y
|
348
|
COMPELLING REASONS FOR CHILD'S BEST INTEREST
|
206 kb
|
06/12/2014
|
Y
|
350
|
QUALIFIED ENTITY APPL RESPONSP/AGREEMENT FOR ND MEDICAID HPE
|
407 kb
|
01/06/2016
|
Y
|
353
|
AFFIDAVIT FOR SNAP EMPLOYMENT AND TRAINING REGISTRANTS
|
920 kb
|
11/23/2020
|
Y
|
361
|
FIRE SAFETY SELF DECLARATION AGENCY/INDIVIDUAL FOSTER HOME
|
1560 kb
|
12/06/2019
|
Y
|
362
|
SNAP COMPUTATION SHEET
|
356 kb
|
06/29/2012
|
Y
|
363
|
REQUEST FOR VERIFICATION OF LIFE INSURANCE POLICY INFORMATIO
|
521 kb
|
07/16/2015
|
Y
|
369
|
APPLICATION FOR FAMILY THERAPY - INTENSIVE
|
786 kb
|
10/22/2010
|
Y
|
372
|
ND MEDICAID HPE ENTITY-REMOVAL OF DESIGNEE
|
630 kb
|
01/06/2016
|
Y
|
375
|
AUTHORIZATION TO TRANSFER BACKGROUND CHECK RESULTS
|
1288 kb
|
12/29/2020
|
Y
|
376
|
FLEEING FELON/PAROLE OR PROBATION VIOLATOR REVIEW
|
370 kb
|
12/14/2017
|
Y
|
379
|
CORRECTION ORDER
|
427 kb
|
06/07/2016
|
Y
|
380
|
UNLICENSED CHILD CARE PROVIDER AFFIDAVIT
|
900 kb
|
12/14/2020
|
Y
|
382
|
CHILD CARE LICENSING LETTER
|
895 kb
|
12/10/2020
|
Y
|
383
|
SERIOUS ACCIDENT INJURY OR ILLNESS REPORT
|
935 kb
|
12/15/2020
|
Y
|
384
|
QUARTERLY REPORT OF FRAUD CONTROL ACTIVITIES
|
651 kb
|
10/03/2016
|
Y
|
385
|
AFFIDAVIT FOR WORK REGISTRANTS
|
920 kb
|
11/23/2020
|
Y
|
386
|
ND MEDICAID HPE ENTITY AUTHORIZATION OF DESIGNEE
|
633 kb
|
01/06/2016
|
Y
|
387
|
ICPC SUPERVISION REPORT
|
248 kb
|
02/26/2009
|
Y
|
394
|
CHILDREN WITH MEDICALLY FRAGILE NEEDS APPLICATION
|
424 kb
|
03/09/2018
|
Y
|
395
|
ICPC/FINANCIAL MEDICAL PLAN
|
128 kb
|
06/12/2014
|
Y
|
400
|
ANNUAL APPLICATION TO PROVIDE FAMILY FOSTER CARE
|
842 kb
|
10/15/2019
|
Y
|
404
|
MEDICAID WAIVER PERSON CENTERED PLAN OF CARE
|
1044 kb
|
07/14/2020
|
Y
|
405
|
APPLICATION FOR ASSISTANCE
|
4454 kb
|
01/02/2020
|
Y
|
407
|
MONTHLY REPORT
|
651 kb
|
02/19/2019
|
Y
|
410
|
AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICES
|
1006 kb
|
12/31/2020
|
Y
|
411
|
AID TO BLIND/REMEDIAL (DENIAL NOTICE)
|
313 kb
|
04/17/2012
|
Y
|
412
|
AID TO BLIND/REMEDIAL (APPROVAL NOTICE)
|
399 kb
|
11/13/2013
|
Y
|
413
|
INDIVIDUAL INDIAN MONIES ACCOUNT
|
400 kb
|
07/25/2012
|
Y
|
414
|
SUBSIDIZED EMPLOYMENT AGREEMENT
|
273 kb
|
08/17/2012
|
Y
|
416
|
MEDICAL APPLICATION-WOMEN'S WAY
|
162 kb
|
09/08/2017
|
Y
|
417
|
RECONCILIATION WITH INVENTORY RECORDS
|
346 kb
|
03/13/2015
|
Y
|
419
|
REQUEST FOR CONFIDENTIAL VERIFICATION OF BIRTH
|
89 kb
|
|
Y
|
420
|
REQUEST FOR VERIFICATION OF DEATH
|
89 kb
|
|
Y
|
421
|
REQUEST FOR VERIFICATION OF MARRIAGE
|
89 kb
|
|
Y
|
422
|
REQUEST FOR VERIFICATION OF DIVORCE
|
87 kb
|
|
Y
|
424
|
KINSHIP CARE AGREEMENT
|
124 kb
|
06/12/2014
|
Y
|
426
|
KINSHIP CARE STUDY
|
1220 kb
|
01/14/2008
|
Y
|
429
|
MEMO AGREEMENT TO ESTABLISH PROTECTIVE PAYMENTS
|
205 kb
|
08/17/2012
|
Y
|
433
|
CHILD ABUSE AND NEGLECT BACKGROUND INQUIRY
|
476 kb
|
03/03/2020
|
Y
|
436
|
COUNTY FILENET DOCUMENT DELETION REQUEST
|
68 kb
|
09/15/2015
|
Y
|
440
|
CHILD CARE REVIEW ERROR CASE FINDINGS
|
381 kb
|
03/27/2017
|
Y
|
441
|
MYAVATAR SECURITY REQUEST
|
1727 kb
|
07/24/2020
|
Y
|
443
|
NOTICE OF RIGHT TO CLAIM GOOD CAUSE
|
111 kb
|
08/21/2012
|
Y
|
445
|
FAMILY EVACUATION DISASTER PLAN
|
915 kb
|
04/15/2019
|
Y
|
446
|
REQUEST TO CLAIM GOOD CAUSE
|
88 kb
|
08/17/2012
|
Y
|
447
|
EXCEPTION FOR SUBMITTING ELECTRONIC CLAIMS
|
301 kb
|
05/22/2020
|
Y
|
450
|
COUNTY SOCIAL SERVICE OFFICE ON SITE REVIEW REPORT
|
290 kb
|
08/09/2010
|
Y
|
451
|
ELIGIBILITY REPORT ON DISABILITY INCAPAS
|
620 kb
|
04/02/2015
|
Y
|
455
|
PRESENT DANGER PLAN
|
908 kb
|
11/05/2020
|
Y
|
458
|
OLDER AMERICANS ACT TITLE III MONITORING TOOL
|
1816 kb
|
08/20/2019
|
Y
|
462
|
REQUEST FOR APPEAL OF THE CA/N ASSESSMENT DECISION
|
901 kb
|
12/26/2019
|
Y
|
471
|
VENDOR PAYMENT AUTHOR & REQUEST FOR PYMT OF GOODS & SERVICES
|
914 kb
|
08/07/2018
|
Y
|
474
|
HCBS CASE CLOSURE/TRANSFER NOTICE/PROVIDER TERMINATION
|
418 kb
|
12/21/2018
|
Y
|
479
|
CONGREGATE MEAL PROGRAM REGISTRATION
|
103 kb
|
08/15/2019
|
N
|
480
|
HOME-DELIVERED MEAL PROGRAM REGISTRATION
|
108 kb
|
08/15/2019
|
N
|
485
|
PLAN OF SAFE CARE FOR SUBSTANCE EXPOSED NEWBORNS, MOTHERS
|
1265 kb
|
10/31/2017
|
Y
|
486
|
REFERRAL FOR CHILD LESS THAN 3 YS TO REGIONAL DD ADMIN
|
1287 kb
|
09/12/2019
|
Y
|
488
|
SNAP CASE REVIEW
|
699 kb
|
11/22/2019
|
Y
|
492
|
ND FAMILY CAREGIVER SUPPORT PROG PROVIDER SERVICE LOG-AGENCY
|
476 kb
|
01/11/2021
|
Y
|
494
|
FOSTER CARE YOUTH TRANSITION CHECKLIST
|
980 kb
|
07/26/2019
|
Y
|
495
|
ALTERNATIVE RESPONSE AGREEMENT
|
861 kb
|
10/24/2017
|
Y
|
496
|
CHILD PROTECTION SERVICES CASE REVIEW
|
653 kb
|
10/19/2009
|
Y
|
497
|
ALTERNATIVE RESPONSE SAFETY SUPPORT AGREEMENT
|
890 kb
|
10/23/2017
|
Y
|
499
|
AFFIDAVIT OF MAILING
|
321 kb
|
01/04/2021
|
Y
|
500
|
SNAP TARGETED CASE REVIEW
|
793 kb
|
12/31/2015
|
Y
|
501
|
HEALTH CARE COVERAGE REVIEW
|
624 kb
|
11/18/2016
|
Y
|
502
|
NOTIFICATION OF QUALITY ASSURANCE/QUALITY CONTROL FINDINGS
|
705 kb
|
11/21/2016
|
Y
|
506
|
STEP TWO - VOLUNTARY TREATMENT PROGRAM
|
707 kb
|
06/05/2015
|
Y
|
507
|
STEP ONE VOLUNTARY TREATMENT PROGRAM APPLICATION
|
709 kb
|
06/05/2015
|
Y
|
514
|
LEVEL II PREADMISSION AND RESIDENT REVIEW ID/RC
|
918 kb
|
09/23/2020
|
Y
|
527
|
GENETIC TESTING SERVICE AUTHORIZATION REQUEST
|
566 kb
|
07/14/2020
|
Y
|
529
|
APPLICATION: LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
|
1151 kb
|
10/20/2020
|
Y
|
530
|
ELIGIBILITY AND BENEFIT WORKSHEET ENERGY
|
1482 kb
|
09/07/2017
|
Y
|
540
|
CONFIDENTIAL REPORT OF JOB INSURANCE
|
260 kb
|
|
Y
|
541
|
APPLICATION TO PROVIDE AGENCY ADULT FOSTER CARE
|
399 kb
|
12/06/2019
|
Y
|
546
|
LIFESPAN RESPITE CARE GRANT PROVIDER SERVICE LOG
|
1289 kb
|
10/11/2019
|
Y
|
548
|
LIFESPAN RESPITE CARE GRANT EMERGENCY RESPITE CARE APP
|
1726 kb
|
10/11/2019
|
Y
|
549
|
RESPITE HOME EVALUATION FAMILY CAREGIVER SUPPORT PROGRAM
|
938 kb
|
11/27/2020
|
Y
|
553
|
CHILDREN'S REGIONAL REVIEW TEAM - INITIAL TEAM REVIEW
|
1290 kb
|
10/22/2020
|
Y
|
558
|
COORDINATED SERVICES PROGRAM (CSP) PROVIDER SELECTION
|
263 kb
|
10/14/2020
|
Y
|
559
|
LIFESPAN RESPITE CARE GRANT EMERG RESPITE PROVIDER AGREEMENT
|
950 kb
|
01/06/2021
|
Y
|
560
|
ASSIGNMENT OF BENEFITS
|
196 kb
|
09/08/2017
|
Y
|
561
|
RECIPIENT RECOVERY THIRD PARTY ATTORNEYS
|
458 kb
|
05/17/2018
|
Y
|
565
|
LIFESPAN RESPITE CARE GRANT RESPITE CARE PROVIDER SERV LOG
|
902 kb
|
10/11/2019
|
Y
|
566
|
MEDICAID QUESTIONNAIRE AND ASSIGNMENT
|
744 kb
|
09/03/2015
|
Y
|
568
|
PASRR LEVEL II EVALUATION FOR ID RELATED CONDITION
|
2174 kb
|
10/22/2020
|
Y
|
570
|
PRE-ENROLLMENT/REVALIDATION SITE VISIT CHECKLIST
|
975 kb
|
12/21/2017
|
Y
|
572
|
HEALTH INSURANCE QUESTIONNAIRE
|
1296 kb
|
03/04/2020
|
Y
|
574
|
PROFESSIONAL DEVELOPMENT/TRAINING REQUEST
|
340 kb
|
02/19/2013
|
Y
|
576
|
EXTENDED PERSONAL CARE SERVICE PROVIDER AGREEMENT
|
310 kb
|
05/21/2020
|
Y
|
577
|
NURSE EDUCATOR NURSING PLAN OF CARE
|
309 kb
|
05/21/2020
|
Y
|
583
|
ND MEDICAID/ELECTRONIC REMITTANCE ADVICE (835) ENROLLMENT
|
921 kb
|
09/18/2020
|
Y
|
584
|
LOCAL CONTACT AGENCY (LCA) REFERRAL
|
1016 kb
|
08/22/2018
|
Y
|
585
|
LOCAL CONTACT AGENCY (LCA) TRANSITION PLAN
|
1011 kb
|
03/16/2017
|
Y
|
586
|
APPLICATION FOR MINOR IN POSSESSION (MIP) PROVIDER
|
938 kb
|
08/01/2019
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Y
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587
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PROVIDER RECERT/CHANGE OF PROGRAM APPLICATION FOR MIP
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917 kb
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09/26/2018
|
Y
|
588
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INITIAL LICENSING STUDY - AGENCY ADULT FOSTER CARE
|
1368 kb
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12/17/2019
|
Y
|
590
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RELICENSING STUDY - AGENCY ADULT FOSTER CARE
|
1369 kb
|
12/18/2019
|
Y
|
591
|
OPIOID TREATMENT PROGRAM LICENSE APPLICATION
|
2052 kb
|
08/28/2020
|
Y
|
594
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APPLICATION FOR RECERTIFICATION: MENTAL HEALTH TECHNICIAN
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596 kb
|
03/31/2016
|
Y
|
596
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APPLICATION FOR CERTIFICATION: MENTAL HEALTH TECHNICIAN
|
494 kb
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03/22/2016
|
Y
|
598
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APPLICATIONS FOR CHILD CARE PROGRAMS
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1616 kb
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05/18/2020
|
Y
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599
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PRTF LICENSURE/REQUEST FOR CHANGE IN BED CAPACITY APPLICATIO
|
950 kb
|
01/06/2021
|
Y
|
600
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PARTICIPANT SERVICE PLAN
|
995 kb
|
09/29/2017
|
Y
|
602
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STAFF INFORMATION SUMMARY
|
627 kb
|
10/20/2016
|
Y
|
616
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CHILD CARE REQUEST FOR PAYMENT
|
1014 kb
|
09/30/2016
|
Y
|
617
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OUT-OF-STATE/TRIBAL CHILD CARE ASSISTANCE PROVIDER AGREEMENT
|
652 kb
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11/30/2015
|
Y
|
620
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NON-EMERGENT MEDICAL TRANSPORTATION
|
1611 kb
|
06/14/2018
|
Y
|
626
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DETERMINE IF A CONTRACT REQUIRES BBA AND A QSO AGREEMENT
|
1247 kb
|
06/10/2020
|
Y
|
630
|
FOSTER CARE PLACEMENT NOTIFICATION
|
1020 kb
|
12/31/2019
|
Y
|
634
|
NORTH DAKOTA PEER SPECIALIST CERTIFICATION APPLICATION
|
994 kb
|
07/02/2020
|
Y
|
636
|
HCBS AGENCY/INDIV FOSTER CARE SETTING EXPERIENCE INTERVIEW
|
1660 kb
|
11/27/2020
|
Y
|
639
|
HCBS ADULT RESIDENTIAL SERVICES SETTING EXPERIENCE INTERVIEW
|
1659 kb
|
11/27/2020
|
Y
|
640
|
VERIFICATION OF PARTICIPATION IN ARSEN PROGRAM
|
1292 kb
|
12/23/2020
|
Y
|
641
|
TITLE IV-E TITLE XIX APPLICATION - FOSTER CARE
|
2318 kb
|
08/12/2019
|
Y
|
642
|
TITILE IV-E/TITLE XIX REDETERMINATION - FOSTER CARE
|
157 kb
|
|
Y
|
643
|
NURSE MGMT AGREEMENT/NPOC INSTRUCT FOR ATTENDANT CARE SERV
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311 kb
|
11/29/2016
|
Y
|
644
|
ATTENDANT CARE SERVICE PROVIDER AGREEMENT
|
371 kb
|
11/08/2016
|
Y
|
648
|
MEDICATION UNIT LICENSE APPLICATION
|
2051 kb
|
09/02/2020
|
Y
|
649
|
AGING & DISABILITIES RESOURCE LINK SERV REFERRAL/APPLICATION
|
904 kb
|
07/17/2020
|
Y
|
651
|
EXCEPTIONAL CIRCUMSTANCES IN HIRING-ND EARLY INTERVENTION
|
1285 kb
|
10/16/2020
|
Y
|
653
|
MEDICAID PROVIDER ELECTRONIC WEB-FILE TRANSFER REGISTRATION
|
336 kb
|
02/02/2015
|
Y
|
655
|
LIHEAP CASE REVIEW
|
821 kb
|
06/18/2012
|
Y
|
658
|
AGING & DISABILITIES RESOURCE LINK RENTAL AGREEMENT
|
904 kb
|
07/16/2020
|
Y
|
659
|
RESPITE HOME EVALUATION
|
516 kb
|
12/22/2017
|
Y
|
660
|
AGING & DISABILITIES RESOURCE LINK MOVING COST REQUEST
|
899 kb
|
07/16/2020
|
Y
|
662
|
PERSONAL CARE SERVICES PLAN OF CARE
|
679 kb
|
08/16/2018
|
Y
|
663
|
AUTHORIZATION TO PROVIDE PERSONAL CARE SERVICES
|
329 kb
|
04/24/2019
|
Y
|
669
|
INITIAL LICENSING STUDY-ADULT FOSTER CARE
|
1374 kb
|
10/28/2020
|
Y
|
676
|
ADD NEW RECORD TO MMIS ELIGIBILITY FILE-SPED & EX-SPED
|
514 kb
|
01/29/2019
|
Y
|
679
|
SNAP EMPLOYMENT & TRAINING REFERRAL
|
902 kb
|
09/17/2018
|
Y
|
680
|
DVR POTENTIALLY ELIGIBLE DATA COLLECTION TOOL
|
931 kb
|
07/02/2020
|
Y
|
687
|
MEDICAID BUDGET WORKSHEET
|
259 kb
|
09/08/2017
|
Y
|
688
|
ASSISTIVE TECHNOLOGY REQUEST - ASD WAIVER ONLY
|
328 kb
|
09/17/2018
|
Y
|
690
|
AFFIDAVIT OF IDENTITY-DISABILED INDIVIDUAL IN FACILITY
|
188 kb
|
09/08/2017
|
Y
|
691
|
AFFIDAVIT OF IDENTITY-FOR CHILDREN
|
257 kb
|
09/08/2017
|
Y
|
692
|
AUTHORIZATION TO PROVIDE (MFP) NURSING ASSESSMENT
|
365 kb
|
01/30/2018
|
Y
|
700
|
CASE TRANSFER LOG
|
541 kb
|
06/19/2013
|
Y
|
704
|
AUTHORIZATION TO PROVIDE (MFP) NURSING ASSESSMENT
|
382 kb
|
12/14/2017
|
Y
|
705
|
HEALTH TRACKS APPOINTMENT SLIP
|
289 kb
|
01/28/2013
|
Y
|
706
|
AFFIDAVIT OF EXPLANATION WHY CITIZENSHIP VERIFY NOT SUPPLIED
|
183 kb
|
09/08/2017
|
Y
|
707
|
CITIZENSHIP AFFIDAVIT
|
289 kb
|
09/08/2017
|
Y
|
710
|
HEALTH TRACKS REFERRAL AND REQUEST FOR INFORMATION
|
296 kb
|
05/11/2020
|
Y
|
718
|
PCARD RECORD
|
387 kb
|
01/03/2013
|
Y
|
719
|
TANF REQUEST FOR BENEFITS
|
403 kb
|
08/17/2012
|
Y
|
734
|
PCARD TRANSMITTAL COVER SHEET
|
176 kb
|
11/24/2009
|
Y
|
735
|
DIVERSION ASSISTANCE SCREENING TOOL
|
192 kb
|
08/17/2012
|
Y
|
736
|
CONTROLLED SUBSTANCE AGREEMENT
|
627 kb
|
11/22/2016
|
Y
|
737
|
DIVERSION ASSISTANCE ACTION PLAN
|
428 kb
|
11/29/2007
|
Y
|
739
|
AUTHORIZATION TO PROVIDE COMPANIONSHIP SERVICES
|
1359 kb
|
09/11/2020
|
Y
|
740
|
COMPANIONSHIP BILLING WORKSHEET
|
1290 kb
|
09/11/2020
|
Y
|
741
|
DIAGNOSIS AND WHODAS FOR 1915(I) ELIGIBILITY
|
2484 kb
|
11/09/2020
|
Y
|
743
|
CHILDRENS' HOSPICE WAIVER APPLICATION
|
361 kb
|
06/25/2019
|
Y
|
747
|
ADULT FOSTER CARE APPEAL
|
631 kb
|
03/09/2017
|
Y
|
768
|
FUNDS MATCH CERTIFICATION
|
885 kb
|
02/24/2020
|
Y
|
770
|
EBT CARD ISSUED BY MAIL
|
208 kb
|
08/09/2010
|
Y
|
772
|
ABSENT PARENT/RELATIVE SEARCH RECORD
|
243 kb
|
02/23/2009
|
Y
|
773
|
WARRANT/CHECK CANCELLATION
|
367 kb
|
09/25/2009
|
Y
|
775
|
CHAIN OF CUSTODY
|
1357 kb
|
07/27/2016
|
Y
|
788
|
GROUP LIVING ARRANGEMENT AND DRUG/ALCOHOL TREATMENT CTR RPT'
|
324 kb
|
08/09/2010
|
Y
|
792
|
OPIOD TREATMENT PROGRAM FEDERAL EXEMPTION REQUEST
|
659 kb
|
11/15/2016
|
Y
|
794
|
SUBSTANCE USE DISORDER VOUCHER (SUD) PRIOR AUTH/CONTIN STAY
|
1236 kb
|
10/03/2018
|
Y
|
805
|
REQUEST FOR EXEMPTION FROM TANF LIFETIME LIMIT
|
180 kb
|
08/17/2012
|
Y
|
807
|
NURSING PLAN OF CARE
|
1062 kb
|
05/17/2017
|
Y
|
811
|
FREE THROUGH RECOVERY (FTR) PROGRAM PROVIDER APPLICATION
|
1681 kb
|
11/17/2020
|
Y
|
814
|
REQUEST FOR BENEFICIARY SERVICE COVERAGE
|
306 kb
|
01/07/2020
|
Y
|
816
|
CHANGE REPORT FOR ADOPTION ASSISTANCE
|
270 kb
|
|
Y
|
817
|
HEALTH INSURANCE COST-EFFECTIVE REVIEW
|
514 kb
|
09/08/2017
|
Y
|
820
|
SPED INCOME AND ASSETS
|
519 kb
|
10/23/2020
|
Y
|
824
|
UNIVERSAL APPLICATION
|
1093 kb
|
11/13/2020
|
Y
|
826
|
QUALIFIED RESDIENTIAL TRMT PROG (QRTP) CONTINUED STAY REVIEW
|
1023 kb
|
11/13/2020
|
Y
|
827
|
CREDIT REPORT
|
932 kb
|
04/07/2020
|
Y
|
828
|
MEDICAL SERVICES PROGRAM REFUND/CREDIT REPORT
|
979 kb
|
04/08/2020
|
Y
|
829
|
PERSONAL AUTHORIZATION FOR CRIMINAL HISTORY RECORD INFO
|
1298 kb
|
12/30/2020
|
Y
|
830
|
REQUEST FOR CLIENT SPECIFIC ENDORSEMENT
|
529 kb
|
04/17/2019
|
Y
|
832
|
EARLY CHILDHOOD SERVICES LICENSE APPLICATION
|
911 kb
|
09/11/2020
|
Y
|
833
|
PATIENT CONSENT FOR TELEMEDICINE ENCOUNTER
|
97 kb
|
03/12/2008
|
N
|
836
|
FINGERPRINT IDENTITY VERIFICATION
|
905 kb
|
12/29/2020
|
Y
|
839
|
FOSTER CARE OVERPAYMENT NOTIFICATION
|
929 kb
|
06/10/2020
|
Y
|
841
|
CHILD CARE ASSISTANCE PROGRAM REVIEW
|
1468 kb
|
10/27/2016
|
Y
|
842
|
PLACEMENT ACKNOWLEDGEMENT FAMILY FOSTER HOMES
|
910 kb
|
09/17/2019
|
Y
|
843
|
FOSTER CARE FINANICAL REPORT
|
944 kb
|
09/16/2019
|
Y
|
844
|
RELATIVE WAIVER FAMILY FOSTER HOMES
|
935 kb
|
09/17/2019
|
Y
|
848
|
CHILD CARE PROVIDER'S REQUEST TO PAY PARENT DIRECTLY
|
192 kb
|
08/17/2012
|
Y
|
850
|
INITIAL LICENSING CHECKLIST FAMILY FOSTER HOMES
|
960 kb
|
09/27/2019
|
Y
|
851
|
ANNUAL LICENSING CHECKLIST FAMILY FOSTER HOME
|
961 kb
|
09/27/2019
|
Y
|
852
|
SENDING STATE EXPEDITED HOME STUDY REQUEST
|
445 kb
|
12/20/2017
|
Y
|
854
|
TITLE IV-E ADOPTION SUBSIDY CERTIFICATION
|
499 kb
|
02/26/2018
|
Y
|
856
|
ADOPTION SUBSIDY AGREEMENT - ANNUAL REVIEW
|
533 kb
|
02/26/2018
|
Y
|
869
|
TITILE IV-E INITIAL ELIGIBILITY
|
1018 kb
|
08/30/2019
|
Y
|
870
|
TITLE IV-E 18+ CONTINUED CARE ELIGIBILITY
|
975 kb
|
08/30/2019
|
Y
|
871
|
HEALTH TRACKS SCREENING RESULTS
|
498 kb
|
07/02/2019
|
Y
|
873
|
TITLE IV-E INCOME CALCULATION WORKSHEET
|
935 kb
|
09/11/2019
|
Y
|
878
|
CROSSROADS EVALUATION (CASE MANAGER)
|
642 kb
|
10/31/2014
|
Y
|
879
|
CROSSROAD EVALUATION (SCHOOL)
|
520 kb
|
10/31/2014
|
Y
|
880
|
SUBSTANCE USE DISORDER (SUD) VOUCHER INDIVIDUAL APPLICATION
|
1008 kb
|
11/05/2020
|
Y
|
885
|
STATEMENT OF CASE WORKER
|
419 kb
|
10/13/2011
|
Y
|
887
|
APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL)
|
1265 kb
|
09/16/2019
|
Y
|
889
|
INITIAL HOME STUDY FOSTER CARE FOR CHILDREN
|
1277 kb
|
10/03/2019
|
Y
|
890
|
AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO
|
419 kb
|
09/05/2019
|
Y
|
892
|
INFORMED CHOICE REFERRAL FOR LONG-TERM CARE
|
959 kb
|
12/23/2020
|
Y
|
893
|
INITIAL APP FOR LIC TO PROVIDE FAMILY FOSTER CARE FOR CHILD
|
873 kb
|
10/15/2019
|
Y
|
898
|
ANNUAL LICENSING APPLICATION QRTP
|
2292 kb
|
09/17/2019
|
Y
|
909
|
RECORDS INVENTORY WORKSHEET
|
839 kb
|
01/16/2019
|
Y
|
915
|
ADULT FOSTER CARE AFFIDAVIT OF STD COMPLIANCE IN LIEU OF LIC
|
565 kb
|
03/16/2017
|
Y
|
918
|
SERVICE MANAGEMENT LOG
|
413 kb
|
07/07/2017
|
Y
|
920
|
FOSTER CARE - CHILD CARE INVOICE
|
1468 kb
|
03/21/2019
|
Y
|
925
|
RESPITE CARE REFERRAL
|
919 kb
|
12/23/2020
|
Y
|
928
|
AGREEMENT TO FURNISH SHELTER CARE
|
947 kb
|
07/16/2020
|
Y
|
929
|
AGREEMENT TO FURNISH RESPITE CARE
|
1513 kb
|
07/16/2020
|
Y
|
944
|
REQUEST FOR ATTENDANT CARE SERVICES
|
519 kb
|
10/31/2016
|
Y
|
950
|
MEDICAID PAYMENT ALERT RCCF/BASIC CARE FACILITY
|
395 kb
|
09/08/2017
|
Y
|
958
|
HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED
|
2233 kb
|
12/31/2019
|
Y
|
963
|
TARGETED CASE MANAGEMENT ASSESSMENT
|
438 kb
|
07/17/2020
|
Y
|
965
|
IC APPLICATION REQUEST TO PLACE CHILD
|
253 kb
|
|
Y
|
966
|
IC REPORT ON PLACEMENT STATUS OF CHILD
|
290 kb
|
06/12/2014
|
Y
|
968
|
REPORTABLE INCIDENTS FOR EXTENDED PERSONAL CARE SERVICE
|
379 kb
|
01/22/2020
|
Y
|
970
|
MULTI-AGENCY AUTHORIZATION TO DISCLOSE INFORMATION
|
329 kb
|
04/10/2014
|
Y
|
971
|
SUBSTANCE ABUSE TREATMENT LICENSE APPLICATION
|
949 kb
|
10/29/2020
|
Y
|
973
|
EXTENDED PERSONAL CARE SERVICE PROVIDER PROCEDURE & TRAINING
|
336 kb
|
04/15/2019
|
Y
|
974
|
PHYSCIAL EXAM VERIFICATION FAMILY FOSTER HOME
|
925 kb
|
09/17/2019
|
Y
|
977
|
SECURITY ACCESS AND PHOTO REQUEST
|
1441 kb
|
11/30/2018
|
Y
|
986
|
COMMUNITY CONNECT PROGRAM PROVIDER APPLICATION
|
1557 kb
|
12/21/2020
|
Y
|
991
|
MEDICAID PAYMENT ALERT
|
411 kb
|
03/04/2020
|
Y
|
992
|
QUALITY ASSURANCE (QA) CASE REVIEW ADOPTION CASE NARRATIVE
|
1708 kb
|
10/05/2020
|
Y
|
993
|
QA CASE REVIEW CHILD PROTECTIVE SERVICES CASE NARRATIVE
|
1715 kb
|
10/08/2020
|
Y
|
995
|
QA CASE REVIEW FOSTER CARE CASE NARRATIVE
|
1304 kb
|
10/19/2020
|
Y
|
996
|
QA CASE REVIEW IN-HOME CASE NARRATIVE
|
1864 kb
|
10/19/2020
|
Y
|
997
|
QA CASE REVIEW SUPERVISOR FOSTER CARE CASE QUESTIONNAIRE
|
1288 kb
|
10/05/2020
|
Y
|
998
|
QA CASE REVIEW SUPERVISOR IN-HOME CASE QUESTIONNAIRE
|
1287 kb
|
10/05/2020
|
Y
|
999
|
COMMUNITY-BASED BEHAVIORAL HEALTH PROG PARTICIPANT ELIGIBIL
|
973 kb
|
11/17/2020
|
Y
|
1008
|
HCBS CASE CLOSURE/TRANSFER NOTICE
|
356 kb
|
07/01/2014
|
Y
|
1009
|
HCBS NOTICE OF REDUCTION, DENIAL OR TERMINATION
|
893 kb
|
11/30/2018
|
Y
|
1010
|
PROVIDER ASSURANCE TO FEDERAL HOME & COMMUNITY BASED SERVICE
|
913 kb
|
10/16/2020
|
Y
|
1011
|
NOTIFICATION OF HCBS SCREENING
|
892 kb
|
06/08/2020
|
Y
|
1012
|
MONTHLY RATE WORKSHEET - LIVE IN CARE
|
741 kb
|
07/31/2020
|
Y
|
1013
|
APPLICATION TO PROVIDE ADULT FOSTER CARE
|
1366 kb
|
10/28/2020
|
Y
|
1018
|
NEW HIRE REPORTING
|
699 kb
|
07/28/2020
|
Y
|
1019
|
HEALTH TRACKS/FAMILY SUPPORT REFERRAL
|
379 kb
|
06/12/2015
|
Y
|
1020
|
LICENSE TO PROVIDE ADULT FOSTER CARE
|
196 kb
|
05/03/2019
|
Y
|
1023
|
FOSTER CARE TRANSPORTATION REIMBURSEMENT BUDGET SHEET
|
437 kb
|
04/22/2015
|
Y
|
1031
|
RELICENSING STUDY ADULT FOSTER CARE
|
1374 kb
|
01/14/2020
|
Y
|
1032
|
REQUEST FROM LAW ENFORCEMENT
|
258 kb
|
01/04/2011
|
Y
|
1033
|
AUTHORIZATION
|
430 kb
|
05/29/2014
|
Y
|
1047
|
APPLICATION FOR SERVICE
|
888 kb
|
12/21/2018
|
Y
|
1050
|
PARIS MATCH OUT OF STATE INQUIRY
|
610 kb
|
09/08/2017
|
Y
|
1059
|
AUTHORIZATION TO DISCLOSE INFORMATION
|
938 kb
|
12/02/2020
|
Y
|
1076
|
GROWERS STATEMENT
|
383 kb
|
08/09/2010
|
Y
|
1081
|
DISCOVERY PROFILE
|
1363 kb
|
01/29/2020
|
Y
|
1088
|
CLIENT FINANCIAL RESPONSIBILITY SUPPLEMENTAL INFORMATION
|
378 kb
|
04/11/2016
|
Y
|
1092
|
REFERRAL FOR EMPLOYMENT SERVICES
|
918 kb
|
09/26/2019
|
Y
|
1095
|
TRIAL WORK EXPERIENCE REPORT
|
1291 kb
|
02/24/2020
|
Y
|
1101
|
MONTHLY PROGRESS SUMMARY
|
1292 kb
|
12/06/2019
|
Y
|
1146
|
NON-PROFIT CLINIC DENTAL ACCESS PROJECT ACPPLICATION
|
311 kb
|
05/20/2020
|
Y
|
1154
|
MEDICAID WAIVER QUALITY REVIEW
|
516 kb
|
01/29/2019
|
Y
|
1168
|
OWNERSHIP CONTROLLING INTEREST AND CONVICTION INFORMATION
|
609 kb
|
08/05/2020
|
Y
|
1172
|
REQUEST FOR AN ADMINISTRATIVE HEARING
|
273 kb
|
02/22/2010
|
Y
|
1177
|
REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS
|
1039 kb
|
08/03/2020
|
Y
|
1186
|
NOTICE TO ISSUE OF ANNUITY OF STATE'S RIGHT AS A PREFERRED
|
202 kb
|
09/08/2017
|
Y
|
1187
|
NORTH DAKOTA GLOBAL CLIENT CONSENT
|
900 kb
|
03/27/2019
|
Y
|
1221
|
INTENSIVE IN-HOME FAMILY SERVICE LOG
|
176 kb
|
|
Y
|
1235
|
VISITOR SIGN-IN LOG
|
1285 kb
|
01/28/2020
|
Y
|
1247
|
INFORMAL MEETING REQUEST FOR FOSTER PARENT GRIEVANCE
|
369 kb
|
09/16/2019
|
Y
|
1248
|
NOTICE OF INFORMAL MEETING CONCERNING GRIEVANCE
|
384 kb
|
09/16/2019
|
Y
|
1249
|
AGENCY SUMMARY OF AND DECISION FROM INFORMAL MEETING
|
391 kb
|
09/16/2019
|
Y
|
1250
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FOSTER PARENT SUMMARY & ALERNATIVE RESOLUTION
|
227 kb
|
09/02/2010
|
Y
|
1251
|
FOSTER PARENT REQUEST FOR FORMAL GRIEVANCE
|
237 kb
|
09/02/2010
|
Y
|
1252
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NOTICE OF GRIEVANCE HEARING
|
263 kb
|
09/02/2010
|
Y
|
1253
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RESULTS OF FORMAL GRIEVANCE HEARING
|
229 kb
|
09/02/2010
|
Y
|
1258
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CHILD CARE FACILITY STAFFING
|
1175 kb
|
01/12/2018
|
Y
|
1259
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CHILD CARE PROVIDER STAFFING
|
1289 kb
|
12/02/2020
|
Y
|
1296
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CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES
|
670 kb
|
08/25/2020
|
Y
|
1297
|
FINGERPRINT VERIFICATION
|
355 kb
|
07/11/2018
|
Y
|
1299
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REQUEST TO ADD/REMOVE A SERVICE LOCATION
|
227 kb
|
10/14/2020
|
Y
|
1302
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REQUEST TO ADD/CHANGE TAXONOMY
|
725 kb
|
01/05/2021
|
Y
|
1330
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REQUEST TO ADD AN AFFILIATION
|
350 kb
|
10/14/2020
|
Y
|
1331
|
PROVIDER TERMINATION
|
356 kb
|
08/07/2020
|
Y
|
1410
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ND MEDICAL ACUITY TIER RATE ADD-ON PROVIDER SUBMISSION
|
929 kb
|
10/22/2020
|
Y
|
1411
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DD PROGRAM MANAGEMENT AGE THREE REDETERMINATION
|
897 kb
|
09/23/2020
|
Y
|
1414
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DEVELOPMENTAL DISABILITIES QUARTERLY PROGRESS SUMMARY
|
1291 kb
|
07/09/2019
|
Y
|
1415
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ND MEDICAL ACUITY TIER RATE ADD-ON SECONDARY ASSESSMENT
|
2600 kb
|
10/16/2020
|
Y
|
1419
|
SIS & INVENTORY FOR ICAP ASSESSMENT REQUEST
|
1287 kb
|
10/16/2020
|
Y
|
1467
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SPED EXSPED INDIVIDUAL CARE PLAN
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935 kb
|
01/29/2019
|
Y
|
1474
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CONTRACTOR-STATE FLEET VEHICLE USE ORIENTATION
|
941 kb
|
06/29/2018
|
Y
|
1478
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NOTICE OF INVALID AUTHORIZATION TO DISCLOSE INFORMATION
|
400 kb
|
01/28/2014
|
Y
|
1525
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SITUATIONAL ASSESSMENT REPORT
|
1364 kb
|
12/18/2019
|
Y
|
1540
|
INCOME ANNUALIZING/AVERAGING WORKSHEET
|
360 kb
|
|
Y
|
1557
|
DD PROGRAM ADMIN/PROGRAM MANAGER ENVIRONMENTAL SCAN CHECKLIS
|
2071 kb
|
01/31/2020
|
Y
|
1558
|
NORTH DAKOTA STATE HOSPITAL INVOICE
|
1286 kb
|
05/14/2020
|
Y
|
1560
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DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY
|
909 kb
|
01/08/2021
|
Y
|
1597
|
EXPLANATION OF CLIENT CHOICE
|
903 kb
|
05/12/2020
|
Y
|
1598
|
MEDICALLY FRAIL QUESTIONNAIRE
|
2094 kb
|
01/30/2018
|
Y
|
1607
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RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT
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1241 kb
|
06/29/2020
|
Y
|
1610
|
VULNERABLE ADULT PROTECTIVE SERVICES INTAKE
|
1710 kb
|
05/05/2020
|
Y
|
1612
|
FOSTER CARE VERIFICATION
|
899 kb
|
07/16/2019
|
Y
|
1613
|
THE CHAFEE PROGRAM - CURRENT FOSTER CARE YOUTH REFERRAL
|
606 kb
|
01/07/2019
|
Y
|
1614
|
THE CHAFEE PROGRAM - FOSTER CARE ALUMNI REFERRAL
|
781 kb
|
01/07/2019
|
Y
|
1615
|
VAPS QUALITY ASSURANCE REVIEW TOOL - INTAKE
|
1364 kb
|
02/05/2020
|
Y
|
1616
|
VAPS QUALITY ASSURANCE REV TOOL-INVESTIGATION-CLOSED CASES
|
1363 kb
|
01/30/2020
|
Y
|
1617
|
VAPS QUALITY ASSURANCE REVIEW TOOL-INVESTIGATION-OPEN CASES
|
1361 kb
|
01/31/2020
|
Y
|
1618
|
HEALTH COVERAGE FROM JOBS
|
665 kb
|
08/30/2013
|
Y
|
1619
|
REQUEST TO BE QUALIFIED SERVICE PROVIDER/AFHA
|
936 kb
|
04/21/2020
|
Y
|
1647
|
HCBS NOTICE OF REDUCTION, DENIAL, OR TERMINATION
|
367 kb
|
01/27/2020
|
Y
|
1681
|
NEAR ZERO INCOME WORKSHEET
|
172 kb
|
|
Y
|
1699
|
AUTHORIZATION TO PROVIDE SERVICES FOR SPED/EXSPED
|
329 kb
|
04/24/2019
|
Y
|
1703
|
COMPLIANCE CHECKLIST/ADULT DAY CARE STAND
|
1208 kb
|
11/01/2016
|
Y
|
1730
|
HCBS FOR ELDERLY/DISABLED & DEVELOPMENTALLY DISABLED BILLING
|
84 kb
|
09/16/2015
|
Y
|
1731
|
MEDICAL TRAVEL/LODGING BILLING
|
110 kb
|
07/25/2017
|
Y
|
1758
|
DEVELOPMENTAL DISABILITIES APPLICATION
|
898 kb
|
10/16/2020
|
Y
|
1764
|
TRADITIONAL SELF-DIRECTED DISABILITY SUPPORT APPLICATION
|
2102 kb
|
01/08/2021
|
Y
|
1765
|
REQUEST FOR REIMBURSEMENT/NON STATE
|
632 kb
|
02/19/2015
|
Y
|
1775
|
AUTHORIZATION FOR OUT-OF-STATE TRAVEL
|
472 kb
|
08/03/2020
|
Y
|
1784
|
APPEAL BACKGROUND REPORT
|
399 kb
|
06/08/2015
|
Y
|
1792
|
SELF-DISCLOSURE OF PREVIOUS CRIMINAL HISTORY
|
896 kb
|
10/16/2020
|
Y
|
1793
|
NORTH DAKOTA DD PROVIDER LETTER OF INTENT APPLICATION
|
1333 kb
|
10/20/2020
|
Y
|
1794
|
NORTH DAKOTA DEVELOPMENTAL DISABILITY PROVIDER APPLICATION
|
959 kb
|
10/16/2020
|
Y
|
1797
|
ICF/IID MEDICALLY INTENSIVE RATE REQUEST
|
1292 kb
|
10/21/2020
|
Y
|
1800
|
EMPLOYMENT READINESS ASSESSMENT
|
1291 kb
|
10/16/2020
|
Y
|
1802
|
SIS & ICAP ASSESSMENT PROVIDER CHECKLIST
|
1999 kb
|
02/07/2018
|
Y
|
1803
|
SUBSIDIZED ADOPTION AGREEMENT
|
641 kb
|
02/26/2018
|
Y
|
1808
|
SIS & ICAP ASSESSMENT PROTOCOLCHECKLIST
|
977 kb
|
10/22/2020
|
Y
|
1810
|
AUTHORIZATION TO PROVIDE DEVELOPMENTAL DISABILITIES SERVICES
|
977 kb
|
01/14/2021
|
Y
|
1811
|
INDIVIDUAL CARE PLAN - DEVELOPMENTAL DISABILITIES
|
1291 kb
|
11/13/2020
|
Y
|
1812
|
ICF/IID PHYSICIAN CERTIFICATION AND RECERTIFICATION
|
901 kb
|
10/20/2020
|
Y
|
1815
|
ASSESSMENT RESULTS
|
926 kb
|
10/16/2020
|
Y
|
1820
|
SPED PROGRAM POOL DATA
|
1328 kb
|
12/03/2019
|
Y
|
1829
|
LONG TERM CARE OMBUDSMAN PROGRAM COMPLAINT INTAKE
|
1013 kb
|
05/04/2016
|
Y
|
1831
|
GUARDIANSHIP SUBSIDY AGREEMENT - ANNUAL REVIEW
|
473 kb
|
04/27/2015
|
Y
|
1832
|
AGREEMENT FOR SUBSIDIZED GUARDIANSHIP
|
342 kb
|
09/18/2013
|
Y
|
1833
|
APPLICATION FOR SUBSIDIZED GUARDIANSHIP
|
176 kb
|
|
Y
|
1834
|
SUBSIDIZED GUARDIANSHIP CONTINGENT APPROVAL REQUEST
|
208 kb
|
|
Y
|
1835
|
OUTLIER REQUEST
|
1800 kb
|
10/16/2020
|
Y
|
1839
|
OUT OF SEQUENCE FOR MAJOR LIFE CHANGING EVENT ASSESSMENT REQ
|
1298 kb
|
10/16/2020
|
Y
|
1859
|
DEVELOPMENTAL DISABILITIES INTAKE INTERVIEW
|
1000 kb
|
10/22/2020
|
Y
|
1862
|
COMMUNITY TRANSITION SERVICES BUDGET TRAD IID/DD WAIVER
|
1289 kb
|
10/16/2020
|
Y
|
1865
|
SPECIALIZED FAMILY FC/ADOPTION ASSISTANCE CARE EVALUATION
|
2135 kb
|
12/30/2020
|
Y
|
1870
|
DUI SEMINAR INSTRUCTOR CERTIFICATION/RECERT APPLICATION
|
913 kb
|
10/12/2017
|
Y
|
1909
|
APPLICATION FOR HEALTH COVERAGE AND HELP PAYING COSTS
|
3856 kb
|
12/23/2019
|
Y
|
1910
|
WORK READINESS ASSESSMENT QUESTIONNAIRE
|
6164 kb
|
10/02/2013
|
Y
|
1921
|
AID TO THE BLIND/REMEDIAL (DENIAL NOTICE)
|
316 kb
|
04/18/2012
|
Y
|
1940
|
TANF/SNAP/CCAP NOTICE OF SUSPECT INTENTIONAL PROG VIOLATION
|
982 kb
|
02/25/2020
|
Y
|
1941
|
ANNUAL LICENSING REPORT-FOSTER CARE FOR CHILDREN
|
809 kb
|
09/20/2019
|
Y
|
1947
|
REQUEST FOR TRUST REVIEW
|
781 kb
|
11/19/2018
|
Y
|
1948
|
IRS SAFEGUARD REVIEW REPORT
|
1046 kb
|
03/22/2019
|
Y
|
1949
|
STATE FLEET DRIVER ID CARD REQUEST
|
352 kb
|
06/30/2014
|
Y
|
1970
|
MOBILE DEVICE REQUEST & AGREEMENT (DEPT & PERSONAL DEVICE
|
967 kb
|
06/15/2020
|
Y
|
1971
|
MOBILE DEVICE REQUEST & AGREEMENT - PERSONALLY OWNED DEVICE
|
948 kb
|
06/15/2020
|
Y
|
1972
|
ACCEPTABLE USE OF DEPARTMENT IT RESOURCES ACKNOWLEDGMENT
|
916 kb
|
06/15/2020
|
Y
|
1976
|
ASSISTIVE TECHNOLOGY AUTHORIZATION-AUTISM WAIVER
|
322 kb
|
11/30/2018
|
Y
|
1977
|
REQUEST FOR CONFIDENTIAL COMMUNICT BY ALTERNATE MEANS OR LOC
|
945 kb
|
04/16/2020
|
Y
|
1978
|
REQUEST TO TRANSMIT ELECTRONIC PHI TO THIRD PARTY
|
646 kb
|
01/12/2017
|
Y
|
1979
|
REQUEST TO ACCESS CONFIDENTIAL INFORMATION
|
484 kb
|
09/30/2013
|
Y
|
1981
|
REQUEST TO AMEND RECORDS-PHI
|
451 kb
|
07/13/2017
|
Y
|
60603
|
GENERAL INCIDENT REPORT
|
1170 kb
|
02/15/2017
|
Y
|
60611
|
APPLICATION FOR AUTISM VOUCHER
|
693 kb
|
05/27/2020
|
Y
|
60615
|
TRANSITION PLAN OFF OF THE AUTISM WAIVER
|
342 kb
|
06/25/2014
|
Y
|
60618
|
APPLICATION FOR NORTH DAKOTA AUTISM WAIVER
|
523 kb
|
10/08/2020
|
Y
|
60620
|
RESPITE AUTHORIZATION-AUTISM WAIVER
|
341 kb
|
11/30/2018
|
Y
|
60677
|
AUTISM VOUCHER PURCHASE REQUEST
|
464 kb
|
08/16/2018
|
Y
|
60680
|
ELIGIBILITY AND LEVEL OF SUPPORT RECOMMENDATIONS (VABS)
|
340 kb
|
11/30/2018
|
Y
|
61714
|
INSPECTION RECORD OF ALL DRUG STORAGE IN MEDICATION ROOM
|
929 kb
|
10/18/2019
|
Y
|