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Department of Human Services - Internal Form(s)

SFNTitleSizeDateFillable
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 Y
587 PROVIDER RECERT/CHANGE OF PROGRAM APPLICATION FOR MIP 917 kb 09/26/2018 Y
588 INITIAL LICENSING STUDY - AGENCY ADULT FOSTER CARE 1368 kb 12/17/2019 Y
590 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 APPLICATION FOR RECERTIFICATION: MENTAL HEALTH TECHNICIAN 596 kb 03/31/2016 Y
596 APPLICATION FOR CERTIFICATION: MENTAL HEALTH TECHNICIAN 494 kb 03/22/2016 Y
598 APPLICATIONS FOR CHILD CARE PROGRAMS 1616 kb 05/18/2020 Y
599 PRTF LICENSURE/REQUEST FOR CHANGE IN BED CAPACITY APPLICATIO 950 kb 01/06/2021 Y
600 PARTICIPANT SERVICE PLAN 995 kb 09/29/2017 Y
602 STAFF INFORMATION SUMMARY 627 kb 10/20/2016 Y
616 CHILD CARE REQUEST FOR PAYMENT 1014 kb 09/30/2016 Y
617 OUT-OF-STATE/TRIBAL CHILD CARE ASSISTANCE PROVIDER AGREEMENT 652 kb 11/30/2015 Y
620 NON-EMERGENT MEDICAL TRANSPORTATION 1611 kb 06/14/2018 Y
626 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 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 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 NOTICE OF GRIEVANCE HEARING 263 kb 09/02/2010 Y
1253 RESULTS OF FORMAL GRIEVANCE HEARING 229 kb 09/02/2010 Y
1258 CHILD CARE FACILITY STAFFING 1175 kb 01/12/2018 Y
1259 CHILD CARE PROVIDER STAFFING 1289 kb 12/02/2020 Y
1296 CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES 670 kb 08/25/2020 Y
1297 FINGERPRINT VERIFICATION 355 kb 07/11/2018 Y
1299 REQUEST TO ADD/REMOVE A SERVICE LOCATION 227 kb 10/14/2020 Y
1302 REQUEST TO ADD/CHANGE TAXONOMY 725 kb 01/05/2021 Y
1330 REQUEST TO ADD AN AFFILIATION 350 kb 10/14/2020 Y
1331 PROVIDER TERMINATION 356 kb 08/07/2020 Y
1410 ND MEDICAL ACUITY TIER RATE ADD-ON PROVIDER SUBMISSION 929 kb 10/22/2020 Y
1411 DD PROGRAM MANAGEMENT AGE THREE REDETERMINATION 897 kb 09/23/2020 Y
1414 DEVELOPMENTAL DISABILITIES QUARTERLY PROGRESS SUMMARY 1291 kb 07/09/2019 Y
1415 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 SPED EXSPED INDIVIDUAL CARE PLAN 935 kb 01/29/2019 Y
1474 CONTRACTOR-STATE FLEET VEHICLE USE ORIENTATION 941 kb 06/29/2018 Y
1478 NOTICE OF INVALID AUTHORIZATION TO DISCLOSE INFORMATION 400 kb 01/28/2014 Y
1525 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 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 RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT 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