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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 634 kb 07/25/2017 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 645 kb 07/16/2015 Y
29 CROSSROADS PROGRAM APPLICATION 468 kb 10/31/2014 Y
32 REHABILITATIVE SERVICES QUESTIONNAIRE 656 kb 07/25/2017 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 1230 kb 05/08/2018 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
52 SPOUSAL ASSETS 505 kb 08/17/2012 Y
56 EXSPED PROGRAM DATA 640 kb 10/27/2016 Y
60 CONTINUED FOSTER CARE AGREEMENT 18+ 392 kb 09/29/2017 Y
61 HEALTH TRACKS COMPREHENSIVE ORTHODONTIC SCREENING 508 kb 01/25/2013 Y
62 EMERGENCY ASSISTANCE APPLICATION 326 kb Y
65 DAILY REMITTANCE LIST 150 kb 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 540 kb 01/15/2015 Y
81 DESIGNATED MEDICAL PROVIDER 369 kb 09/11/2012 Y
91 REVOCATION OF AUTHORIZATION TO DISCLOSE INFORMATION 340 kb 09/30/2013 Y
94 SECURITY REQUEST FOR ACCESS TO DEVELOPMENTAL DISABILITIES SY 458 kb 01/04/2017 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
113 POST SECONDARY EDUCATION INFORMATION 336 kb 02/08/2013 Y
128 ND FAMILY CAREGIVER SUPPORT PROGRAM PROVIDER AGREEMENT 1393 kb 05/15/2017 Y
132 PHYSICIAN STATEMENT FOR MEDICAID TEMPORARY STAY REVIEW 334 kb 06/11/2015 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 418 kb 02/04/2016 N
150 60 MONTH LIFETIME EXEMPTION BACKGROUND REPORT 175 kb Y
152 CHILD SUPPORT VERIFICATION 108 kb Y
162 REQUEST FOR HEARING 389 kb 06/09/2015 Y
164 SUBRECIPIENT RISK ASSESSMENT CHECKLIST 800 kb 06/30/2017 Y
165 CAREGIVER OPTION PLAN 735 kb 12/01/2017 Y
170 TAXI TRANSPORTATION VOUCHER 265 kb 07/25/2017 Y
171 FOSTER PROGRAM SUBSIDIZED EMPLOYMENT AGREEMENT 247 kb 02/03/2010 Y
173 SUBRECIPIENT RISK ASSESSMENT CHECKLIST-COUNTIES 816 kb 07/17/2017 Y
175 INDIVIDUAL REQUEST TO BE A QSP FOR RESPITE CARE 1413 kb 12/04/2017 Y
177 MMIS ATTACHMENT COVER SHEET 362 kb 08/31/2015 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
201 CBCU TRANSMITTAL 533 kb 08/21/2017 Y
202 GROUP HOME & DRUG/ALCOHOL TREATMENT CTRS MONTHLY LISTING 345 kb 10/08/2012 Y
206 STATUS TRACKING LOG 831 kb 03/26/2018 Y
208 CARD PROBLEM REPORT 419 kb 12/02/2013 Y
212 RURAL DIFFERENTIAL CLOSURE 388 kb 10/31/2016 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
232 DEVELOPMENTAL DISABILITIES RATE CHANGE 628 kb 01/09/2017 Y
244 PURCHASE ORDER/PURCHASE CARD CONFIRMATION 288 kb 10/29/2009 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 571 kb 07/07/2017 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
337 SNAP CLAIM REVIEW 706 kb 09/09/2015 Y
338 CHILDCARE CHECKLIST 660 kb 04/22/2014 Y
339 MONTHLY CASE MGMT BILLING & REPORTING 359 kb 12/26/2007 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 BEST REGISTRANTS 320 kb 08/17/2012 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 NOTICE OF ASSIGNMENT OF SUPPORT RIGHTS (FOSTER CARE) 141 kb 08/09/2010 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 SNAP REQUIREMENTS 318 kb 08/17/2012 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 721 kb 09/23/2016 Y
404 PERSON CENTERED PLAN OF CARE 1053 kb 09/07/2017 Y
407 MONTHLY REPORT 782 kb 01/05/2018 Y
410 AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICES 852 kb 08/24/2017 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 477 kb 12/07/2017 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 540 kb 05/02/2014 Y
446 REQUEST TO CLAIM GOOD CAUSE 88 kb 08/17/2012 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 4770 kb 05/17/2018 Y
471 VENDOR PAYMENT AFDC AUTH AND REQUEST FOR PYMT OF GOODS & SER 449 kb 08/17/2012 Y
474 HCBS CASE CLOSURE/TRANSFER NOTICE 435 kb 05/31/2017 Y
485 PLAN OF SAFE CARE FOR SUBSTANCE EXPOSED NEWBORNS, MOTHERS 1265 kb 10/31/2017 Y
488 SNAP CASE REVIEW 772 kb 03/16/2015 Y
492 ND FAMILY CAREGIVER SUPPORT PROG PROVIDER SERVICE LOG-AGENCY 473 kb 05/25/2017 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 ENERGY ASSISTANCE PROGRAM 1458 kb 10/30/2017 Y
530 ELIGIBILITY AND BENEFIT WORKSHEET ENERGY 1482 kb 09/07/2017 Y
540 CONFIDENTIAL REPORT OF JOB INSURANCE 260 kb Y
549 RESPITE HOME EVALUATION FAMILY CAREGIVER SUPPORT PROGRAM 902 kb 12/29/2017 Y
560 ASSIGNMENT OF BENEFITS 196 kb 09/08/2017 Y
561 RECIPIENT RECOVERY THIRD PARTY ATTORNEYS 458 kb 05/17/2018 Y
566 MEDICAID QUESTIONNAIRE AND ASSIGNMENT 744 kb 09/03/2015 Y
570 PRE-ENROLLMENT/REVALIDATION SITE VISIT CHECKLIST 975 kb 12/21/2017 Y
574 PROFESSIONAL DEVELOPMENT/TRAINING REQUEST 340 kb 02/19/2013 Y
576 EXTENDED PERSONAL CARE SERVICE PROVIDER AGREEMENT 365 kb 11/07/2016 Y
577 NURSE EDUCATOR NURSING PLAN OF CARE 358 kb 11/07/2016 Y
583 ND MEDICAID/ELECTRONIC REMITTANCE ADVICE (835) ENROLLMENT 1061 kb 07/25/2017 Y
584 LOCAL CONTACT AGENCY (LCA) REFERRAL 1003 kb 06/02/2017 Y
585 LOCAL CONTACT AGENCY (LCA) TRANSITION PLAN 1011 kb 03/16/2017 Y
586 APPLICATION FOR MINOR IN POSSESSION (MIP) PROVIDER 1694 kb 06/01/2018 Y
587 PROVIDER RECERT/CHANGE OF PROGRAM APPLICATION FOR MIP 914 kb 06/05/2018 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 1638 kb 02/12/2018 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
613 CLIENT NOTICE 317 kb 09/29/2017 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
630 FOSTER CARE PLACEMENT NOTIFICATION & PRELIM ELIGIBLITY DET 868 kb 05/01/2015 Y
636 HCBS AFC SETTING EXPERIENCE INTERVIEW 698 kb 03/09/2017 Y
641 TITLE IV-E/TITLE XIX APPLICATION - FOSTER CARE 2249 kb 04/19/2017 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
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 SERVICE PLAN 692 kb 04/15/2015 Y
663 AUTHORIZATION TO PROVIDE PERSONAL CARE SERVICES 475 kb 06/02/2016 Y
669 INITIAL LICENSING STUDY-ADULT FOSTER CARE 1475 kb 03/06/2017 Y
676 ADD NEW RECORD TO MMIS ELIGIBILITY FILE-SPED & EX-SPED 467 kb 10/31/2016 Y
679 BASIC EMPLOYMENT SKILLS TRAINING PROGRAM REFERRAL 388 kb 07/07/2017 Y
687 MEDICAID BUDGET WORKSHEET 259 kb 09/08/2017 Y
688 ASSISTIVE TECHNOLOGY REQUEST - ASD WAIVER ONLY 413 kb 05/17/2017 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
701 CASE REVIEW SHORT FORM 812 kb 09/13/2012 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 48 kb 08/17/2012 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 310 kb 08/17/2012 Y
747 ADULT FOSTER CARE APPEAL 631 kb 03/09/2017 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
783 SUBSTANCE USE DISORDER (SUD) VOUCHER INDIVIDUAL APPLICATION 1179 kb 10/05/2017 Y
784 SUD VOUCHER PRIOR AUTHORIZATION/CONTINUED STAY 1233 kb 04/17/2018 Y
787 SUD VOUCHER EXCEPTION REQUEST 1087 kb 10/12/2016 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
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 1685 kb 11/14/2017 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 534 kb 04/02/2015 Y
827 CREDIT REPORT 473 kb 09/04/2013 Y
828 MEDICARE PREMIUM REPAYMENT CREDIT REPORT 521 kb 09/04/2013 Y
830 REQUEST FOR CLIENT SPECIFIC ENDORSEMENT 528 kb 11/01/2016 Y
831 PERSONAL AUTH CRIMINAL HISTORY BCKGRND CHECK INQ/EARLY CHILD 631 kb 12/20/2017 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
841 CHILD CARE ASSISTANCE PROGRAM REVIEW 1468 kb 10/27/2016 Y
848 CHILD CARE PROVIDER'S REQUEST TO PAY PARENT DIRECTLY 192 kb 08/17/2012 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 721 kb 04/09/2008 Y
870 TITLE IV-E REIMBURSABILITY 256 kb Y
871 ND HEALTH TRACKS SCREENING RESULTS 381 kb 05/12/2010 Y
873 INCOME CALCULATION WORKSHEET - TITLE IV-E 123 kb Y
874 OFFICIAL REQUEST FOR CUSTOMER FINANCIAL RECORDS 1062 kb 04/19/2017 Y
878 CROSSROADS EVALUATION (CASE MANAGER) 642 kb 10/31/2014 Y
879 CROSSROAD EVALUATION (SCHOOL) 520 kb 10/31/2014 Y
885 STATEMENT OF CASE WORKER 419 kb 10/13/2011 Y
889 INITIAL HOME STUDY FOSTER CARE FOR CHILDREN 1092 kb 11/02/2016 Y
890 AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO 416 kb 08/23/2016 Y
893 INITIAL APP FOR LIC TO PROVIDE FAMILY FOSTER CARE FOR CHILD 740 kb 09/28/2016 Y
909 RECORDS INVENTORY WORKSHEET 795 kb 06/05/2018 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
928 AGREEMENT TO FURNISH SHELTER CARE 910 kb 11/06/2017 Y
929 AGREEMENT TO FURNISH RESPITE CARE 1426 kb 11/06/2017 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 2053 kb 09/08/2017 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 383 kb 03/24/2017 Y
970 MULTI-AGENCY AUTHORIZATION TO DISCLOSE INFORMATION 329 kb 04/10/2014 Y
971 SUBSTANCE ABUSE TREATMENT LICENSE APPLICATION 557 kb 02/12/2018 Y
980 INDIVIDUAL REQUEST TO BE A QSP/AFFC PROVICER 579 kb 11/01/2012 Y
991 MEDICAID PAYMENT ALERT 416 kb 09/08/2017 Y
1008 HCBS CASE CLOSURE/TRANSFER NOTICE 356 kb 07/01/2014 Y
1009 HCBS NOTICE OF REDUCTION, DENIAL OR TERMINATION 357 kb 07/01/2014 Y
1012 MONTHLY RATE WORKSHEET - LIVE IN CARE 735 kb 10/31/2016 Y
1013 APPLICATION TO PROVIDE ADULT FOSTER CARE 736 kb 03/06/2017 Y
1019 HEALTH TRACKS/FAMILY SUPPORT REFERRAL 379 kb 06/12/2015 Y
1023 FOSTER CARE TRANSPORTATION REIMBURSEMENT BUDGET SHEET 437 kb 04/22/2015 Y
1031 RELICENSING STUDY ADULT FOSTER CARE 1487 kb 03/09/2017 Y
1032 REQUEST FROM LAW ENFORCEMENT 258 kb 01/04/2011 Y
1033 AUTHORIZATION 430 kb 05/29/2014 Y
1050 PARIS MATCH OUT OF STATE INQUIRY 610 kb 09/08/2017 Y
1059 AUTHORIZATION TO DISCLOSE INFORMATION 129 kb 08/17/2012 Y
1076 GROWERS STATEMENT 383 kb 08/09/2010 Y
1088 CLIENT FINANCIAL RESPONSIBILITY SUPPLEMENTAL INFORMATION 378 kb 04/11/2016 Y
1154 MEDICAID WAIVER QUALITY REVIEW 524 kb 11/18/2016 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
1176 CONFIDENTIALITY OF SUBSTANCE USE DISORDER PATIENT ID INFO 331 kb 03/23/2017 Y
1186 NOTICE TO ISSUE OF ANNUITY OF STATE'S RIGHT AS A PREFERRED 202 kb 09/08/2017 Y
1221 INTENSIVE IN-HOME FAMILY SERVICE LOG 176 kb Y
1247 INFORMAL MEETING REQUEST FOR FOSTER PARENT GRIEVANCE 232 kb 09/02/2010 Y
1248 NOTICE OF INFORMAL MEETING CONCERNING GRIEVANCE 256 kb 09/02/2010 Y
1249 AGENCY SUMMARY OF AND DECISION FROM INFORMAL MEETING 262 kb 09/02/2010 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
1330 REQUEST TO ADD AN AFFILIATION 405 kb 07/25/2017 Y
1331 PROVIDER TERMINATION 436 kb 08/30/2017 Y
1411 DD PROGRAM MANAGEMENT REDETERMINATION 353 kb 04/10/2015 Y
1467 INDIVIDUAL CARE PLAN 623 kb 11/22/2016 Y
1474 CONTRACTOR-STATE FLEET VEHICLE USE ORIENTATION 814 kb 07/26/2017 Y
1478 NOTICE OF INVALID AUTHORIZATION TO DISCLOSE INFORMATION 400 kb 01/28/2014 Y
1540 INCOME ANNUALIZING/AVERAGING WORKSHEET 360 kb Y
1593 EXTENDED SERVICES EMPLOYMENT PLAN 431 kb 03/13/2012 Y
1594 EXTENDED SERIVCES VERIFICATION OF AVAILABLE FUNDS 460 kb 03/13/2012 Y
1597 EXPLANATION OF CLIENT CHOICE 372 kb 11/01/2016 Y
1598 MEDICALLY FRAIL QUESTIONNAIRE 2094 kb 01/30/2018 Y
1607 RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT 1170 kb 01/09/2018 Y
1618 HEALTH COVERAGE FROM JOBS 665 kb 08/30/2013 Y
1647 HCBS NOTICE OF REDUCTION, DENIAL, OR TERMINATION 371 kb 11/01/2016 Y
1681 NEAR ZERO INCOME WORKSHEET 172 kb Y
1699 HCBS AUTHORIZATION TO PROVIDE SERVICES 492 kb 11/29/2016 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
1765 REQUEST FOR REIMBURSEMENT/NON STATE 632 kb 02/19/2015 Y
1775 AUTHORIZATION FOR OUT-OF-STATE TRAVEL 470 kb 03/29/2017 Y
1784 APPEAL BACKGROUND REPORT 399 kb 06/08/2015 Y
1793 NORTH DAKOTA DD PROVIDER LETTER OF INTENT APPLICATION 1276 kb 06/06/2018 Y
1794 NORTH DAKOTA DD PROVIDER APPLICATION 1275 kb 06/06/2018 Y
1797 ICF/IID MEDICALLY INTENSIVE RATE REQUEST 1275 kb 05/25/2018 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 650 kb 09/09/2015 Y
1811 INDIVIDUAL CARE PLAN - DD 555 kb 02/18/2015 Y
1812 IFC/IID PHYSICIAN CERTIFICATION AND RECERTIFICATION 766 kb 09/15/2017 Y
1815 ASSESSMENT RESULTS 1276 kb 04/02/2018 Y
1818 MCH HEALTH TRACKS HEALTH HISTORY 1028 kb 08/17/2012 Y
1819 MCH HEALTH TRACKS PEDIATRIC ASSESSMENT 658 kb 08/17/2012 Y
1820 SPED PROGRAM POOL DATA 642 kb 05/04/2016 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
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
1871 ASSURANCE OF COMPLIANCE 312 kb 06/05/2015 Y
1909 APPLICATION FOR HEALTH COVERAGE AND HELP PAYING COSTS 4661 kb 03/22/2016 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 1707 kb 05/24/2018 Y
1941 ANNUAL LICENSING REPORT-FOSTER CARE FOR CHILDREN 683 kb 12/22/2016 Y
1947 REQUEST FOR TRUST REVIEW 657 kb 06/13/2016 Y
1948 IRS SAFEGUARD REVIEW REPORT 1701 kb 04/16/2018 Y
1949 STATE FLEET DRIVER ID CARD REQUEST 352 kb 06/30/2014 Y
1977 REQUEST FOR CONFIDENTIAL COMMUNICT BY ALTERNATE MEANS OR LOC 416 kb 07/06/2015 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 465 kb 06/01/2018 Y
60615 TRANSITION PLAN OFF OF THE AUTISM WAIVER 342 kb 06/25/2014 Y
60618 ND AUTISM WAIVER APPLIATION 780 kb 03/09/2018 Y
60619 WAIVER APPLICATION CASE ACTION REPORT 446 kb 06/25/2014 Y
60620 MMIS AUTHORIZATION-AUTISM WAIVER 368 kb 08/29/2017 Y
60677 AUTISM VOUCHER PURCHASE REQUEST 407 kb 05/16/2017 Y
60680 ELIGIBILITY AND LEVEL OF SERVICE RECOMMENDATIONS 535 kb 07/01/2014 Y