Forms

Because of the Adobe forms technology, it is highly recommended that Internet Explorer 11 or later is used for accessing PDF forms whenever possible. Microsoft Edge is not recommended or supported. If you must use Chrome or Firefox, please follow the instructions listed below.

Adobe PDF Viewer

PDF forms require an Adobe PDF Viewer browser plug-in. The latest versions of Chrome and Firefox do not support this technology by default. Some additional configurations need to be made to these browsers for them to work properly. Depending on your version of Chrome or Firefox, the instructions may vary slightly. When possible, use Internet Explorer 11 or higher. Adobe Reader needs to be installed on your machine. After Adobe Reader is installed, proceed with the instructions below for your specific browser.

Chrome

Replace the Chrome built in PDF viewer so that you can open, view, and save PDF's without issues.

  • Type into the address window of Chrome browser: chrome://settings/content
  • Scroll down and click on PDF documents
  • Slide the slider to the right next to Open PDFs using a different
  • Click on a form number hyperlink
  • Click on the up arrow on the pdf download box in lower left corner of screen
  • Choose Always open in Adobe Reader

Firefox

Trying to open PDFs in Firefox could result in an error message that states "This PDF document contains forms. The filling of form fields is not supported."

To get the form to open in Adobe, you need to do the following:

  • Open Firefox
  • Click the Tools menu button
  • Click Options and select Applications
  • Find Portable Document Format (PDF) in the Content Type column
  • In the Action column, change it to Use Adobe Acrobat

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 937 kb 05/15/2019 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 693 kb 01/03/2017 Y
44 COMPOSING SERVICES REQUEST 677 kb 11/28/2016 Y
45 NOTICE OF CHANGE 832 kb 06/09/2020 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 508 kb 01/25/2013 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
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 1393 kb 05/15/2017 Y
132 PHYSICIAN STATEMENT FOR MEDICAID TEMPORARY STAY REVIEW 903 kb 01/29/2019 Y
133 PROVIDER SURVEY REPORT OF FINDINGS 1231 kb 05/25/2018 Y
136 PLAN OF CORRECTION HCBS SURVEY 1010 kb 01/05/2017 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 773 kb 05/20/2020 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 02/27/2020 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 07/01/2020 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 1217 kb 01/12/2018 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
232 DEVELOPMENTAL DISABILITIES RATE CHANGE 628 kb 01/09/2017 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 LIFESPAN RESPITE ENVIRONMENTAL SCAN DATA COLLECTION 730 kb 05/02/2018 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 909 kb 08/29/2018 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
368 RECIPIENT OVERPAYMENT 2237 kb 11/05/2019 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 900 kb 04/24/2020 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 383 kb 06/07/2016 Y
382 CHILD CARE LICENSING LETTER 302 kb 04/10/2012 Y
383 SERIOUS ACCIDENT INJURY OR ILLNESS REPORT 591 kb 01/31/2018 Y
384 QUARTERLY REPORT OF FRAUD CONTROL ACTIVITIES 651 kb 10/03/2016 Y
385 AFFIDAVIT FOR WORK REGSISTRANTS 909 kb 08/29/2018 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 679 kb 07/29/2019 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 937 kb 01/17/2020 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
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
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 473 kb 05/25/2017 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 323 kb 01/01/2016 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 AND REIVE ID/RC 472 kb 06/15/2017 Y
527 GENETIC TESTING SERVICE AUTHORIZATION REQUEST 457 kb 05/24/2018 Y
529 APPLICATION: LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 1136 kb 08/15/2019 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 902 kb 12/29/2017 Y
553 CHILDREN'S REGIONAL REVIEW TEAM - INITIAL TEAM REVIEW 1290 kb 01/27/2020 Y
559 LIFESPAN RESPITE CARE GRANT EMERG RESPITE PROVIDER AGREEMENT 947 kb 10/11/2019 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 2171 kb 11/12/2019 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 1061 kb 07/25/2017 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 1474 kb 03/16/2016 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 508 kb 06/05/2015 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 1659 kb 12/06/2019 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
651 EXCEPTIONAL CIRCUMSTANCES IN HIRING-ND EARLY INTERVENTION 1285 kb 07/02/2020 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
659 RESPITE HOME EVALUATION 516 kb 12/22/2017 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 1373 kb 01/07/2020 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
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 1680 kb 03/05/2020 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 521 kb 08/15/2018 Y
824 UNIVERSAL APPLICATION 1107 kb 09/27/2019 Y
826 QUALIFIED RESDIENTIAL TRMT PROG (QRTP) CONTINUED STAY REVIEW 1038 kb 09/26/2019 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 02/24/2020 Y
830 REQUEST FOR CLIENT SPECIFIC ENDORSEMENT 529 kb 04/17/2019 Y
832 APPLICATION TO BE LICENSED/EARLY CHILDHOOD SERVICES 1221 kb 01/12/2018 Y
833 PATIENT CONSENT FOR TELEMEDICINE ENCOUNTER 97 kb 03/12/2008 N
836 FINGERPRINT IDENTITY VERIFICATION 678 kb 06/22/2020 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
874 OFFICIAL REQUEST FOR CUSTOMER FINANCIAL RECORDS 921 kb 03/19/2020 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 1006 kb 03/05/2020 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
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
928 AGREEMENT TO FURNISH SHELTER CARE 910 kb 11/06/2017 Y
929 AGREEMENT TO FURNISH RESPITE CARE 1512 kb 02/25/2020 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 462 kb 08/17/2012 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 581 kb 10/24/2018 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
991 MEDICAID PAYMENT ALERT 411 kb 03/04/2020 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 677 kb 07/20/2018 N
1011 NOTIFICATION OF HCBS SCREENING 892 kb 06/08/2020 Y
1012 MONTHLY RATE WORKSHEET - LIVE IN CARE 726 kb 08/01/2019 Y
1013 APPLICATION TO PROVIDE ADULT FOSTER CARE 732 kb 12/26/2019 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 936 kb 10/01/2019 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 807 kb 06/14/2018 Y
1172 REQUEST FOR AN ADMINISTRATIVE HEARING 273 kb 02/22/2010 Y
1173 REGIONAL REFERRAL COMMITTEE RECOMMENDATION 427 kb 11/09/2011 Y
1177 REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS 1038 kb 02/20/2020 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 1174 kb 01/12/2018 Y
1296 CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES 699 kb 10/18/2017 Y
1297 FINGERPRINT VERIFICATION 355 kb 07/11/2018 Y
1299 REQUEST TO ADD/REMOVE A SERVICE LOCATION 223 kb 10/04/2018 Y
1330 REQUEST TO ADD AN AFFILIATION 405 kb 10/16/2019 Y
1331 PROVIDER TERMINATION 436 kb 08/30/2017 Y
1410 ND MEDICAL ACUITY TIER RATE ADD-ON PROVIDER SUBMISSION 927 kb 06/22/2020 Y
1411 DD PROGRAM MANAGEMENT REDETERMINATION 353 kb 04/10/2015 Y
1414 DEVELOPMENTAL DISABILITIES QUARTERLY PROGRESS SUMMARY 1291 kb 07/09/2019 Y
1415 ND MEDICAL ACUITY TIER RATE ADD-ON SECONDARY ASSESSMENT 2584 kb 07/02/2020 Y
1419 SIS & INVENTORY FOR ICAP ASSESSMENT REQUEST 1275 kb 12/21/2018 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
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 HCBC 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 897 kb 10/14/2019 Y
1765 REQUEST FOR REIMBURSEMENT/NON STATE 632 kb 02/19/2015 Y
1775 AUTHORIZATION FOR OUT-OF-STATE TRAVEL 470 kb 06/04/2019 Y
1784 APPEAL BACKGROUND REPORT 399 kb 06/08/2015 Y
1792 SELF-DISCLOSURE OF PREVIOUS CRIMINAL HISTORY 896 kb 07/02/2020 Y
1793 NORTH DAKOTA DD PROVIDER LETTER OF INTENT APPLICATION 1321 kb 07/13/2018 Y
1794 NORTH DAKOTA DEVELOPMENTAL DISABILITY PROVIDER APPLICATION 947 kb 08/01/2018 Y
1797 ICF/IID MEDICALLY INTENSIVE RATE REQUEST 1292 kb 12/05/2019 Y
1800 EMPLOYMENT READINESS ASSESSMENT 1291 kb 05/27/2020 Y
1801 DD VACANCY REQUEST 732 kb 03/14/2018 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 649 kb 02/07/2018 Y
1810 AUTHORIZATION TO PROVIDE SERVICES-DD 638 kb 08/27/2018 Y
1811 INDIVIDUAL CARE PLAN - DD 555 kb 02/18/2015 Y
1812 ICF/IID PHYSICIAN CERTIFICATION AND RECERTIFICATION 766 kb 09/15/2017 Y
1815 ASSESSMENT RESULTS 1276 kb 04/02/2018 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 1787 kb 04/30/2018 Y
1839 OUT OF SEQUENCE FOR MAJOR LIFE CHANGING EVENT ASSESSMENT REQ 1281 kb 05/25/2018 Y
1859 DEVELOPMENTAL DISABILITIES INTAKE INTERVIEW 1000 kb 04/09/2020 Y
1862 COMMUNITY TRANSITION SERVICES BUDGET TRAD IID/DD WAIVER 1289 kb 04/10/2019 Y
1865 SPECIALIZED FAMILY FC/ADOPTION ASSISTANCE CARE EVALUATION 1694 kb 05/23/2018 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 742 kb 09/18/2018 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