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Department of Human Services - Public Form(s)

SFNTitleSizeDateFillable
2 FFATA CERTIFICATION 322 kb 11/06/2012 Y
9 MEDICAID REHAB SERVICES PROVIDER ENROLLMENT ATTESTATION 938 kb 09/29/2020 Y
15 HOME HEALTH EXTENDED HOME HEALTH REQUEST FOR SERV AUTHORIZAT 267 kb 09/03/2014 Y
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 693 kb 03/22/2021 Y
29 CROSSROADS PROGRAM APPLICATION 468 kb 10/31/2014 Y
45 NOTICE OF CHANGE 841 kb 02/16/2021 Y
49 CHILD CARE ASSISTANCE PROGRAM DIRECT DEPOSIT BANKING INFO 1079 kb 02/10/2016 Y
53 CHILDREN'S HOSPICE PERSON-CENTERED CARE PLAN 434 kb 06/24/2019 Y
55 STATEMENT ACTUAL COSTS-IN HOME SEVICE 78 kb N
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
64 RQUEST FOR EXTRA TIME INDIVIDUALS WITH DEVELOPMENTAL DISABIL 347 kb 05/01/2017 Y
73 PARTIAL HOSPITALIZATION PROGRAM (PHP) SERVICE AUTHORIZATION 439 kb 10/26/2020 Y
79 SUBSTANCE USE DISORDER SERVICE AUTHORIZATION REQUEST 563 kb 10/29/2020 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
114 NURSING FACILITY REQUEST FOR STATE RETRO LEVEL OF CARE REVIE 382 kb 03/01/2018 Y
116 QUALITY ASSURANCE CHECKLIST-EARLY CHILDHOOD SERVICES 923 kb 12/16/2020 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
135 ND FAMILY CAREGIVER SUPPORT PROVIDER SERV LOG-INDIVIDUAL 478 kb 01/11/2021 Y
136 PLAN OF CORRECTION HCBS SURVEY 1236 kb 10/16/2020 Y
143 CIVIL RIGHTS COMPLAINT 933 kb 11/02/2018 Y
152 CHILD SUPPORT VERIFICATION 108 kb Y
161 DIRECT DEPOSIT ENROLLMENT AND AUTHORIZATION 390 kb 06/24/2020 Y
162 REQUEST FOR HEARING 911 kb 02/25/2020 Y
168 NORTH DAKOTA MEDICAID PROVIDER APPEAL 895 kb 02/25/2020 Y
171 FOSTER PROGRAM SUBSIDIZED EMPLOYMENT AGREEMENT 247 kb 02/03/2010 Y
172 IN-HOME SUPPORT APPLICATION 2136 kb 10/16/2020 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
200 ASSET ASSESSMENT 1096 kb 09/08/2017 Y
209 CHILDCARE FACILITY FIRE DRILL RECORD 225 kb Y
212 RURAL DIFFERENTIAL UNIT RATE AUTHORIZATION/CLOSURE 504 kb 01/31/2019 Y
223 FIRE INSPECTION CERTIFICATION 1447 kb 12/01/2020 Y
224 PRIVATE DUTY NURSING SERVICE AUTHORIZATION 422 kb 09/03/2014 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
234 INSURANCE COVERAGE STATEMENT 898 kb 09/23/2020 Y
235 CRIMINAL OFFENSE CONVICTION STATEMENT 1286 kb 10/16/2020 Y
236 FINANCIAL DISCLOSURE STATEMENT 894 kb 10/16/2020 Y
247 MINIMUM DATA SET (MDS) APPEALS REQUEST 384 kb 03/04/2020 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
269 MONTHLY DATA AND PAYMENT REPORT 636 kb 09/09/2015 Y
270 REQUEST FOR REPLACEMENT DUE TO LOSS OF FOOD PURCHASED WITH S 341 kb 08/17/2012 Y
292 REQUEST FOR SERVICE AUTHORIZATION FOR VISION SERVICES 602 kb 07/20/2018 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
303 SNAP GROUP LIVING ARRANGEMENT & DRUG/ALCOHOL TRTM EXIT NOTIF 381 kb 03/10/2016 Y
308 MEDICAID & BASIC CARE ASSISTANCE PROGRAM AGREEMENT 175 kb 07/25/2017 Y
312 CORRECTION ORDER NOTIFICATION & CHILD CARE PROVIDER CONFIRM 192 kb 06/12/2013 Y
323 JOBS STATUS CHANGE 158 kb 11/08/2012 Y
327 FOSTER FAMILY CARE HOME CLAIM OF PROPERTY DAMAGE 392 kb 09/05/2019 Y
328 FAMILY FOSTER CARE HOME PROP DAMAGE VERIFICATION OF CLAIM 496 kb 09/05/2019 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
344 THERAPEUTIC PET OR SERVICE ANIMAL REQUEST 907 kb 11/08/2019 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
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
373 AUTHORIZATION FOR BACKGROUND CHECK/MILITARY & RESERVATIONS 319 kb 12/02/2008 Y
374 APPLICATION CONTRACT FOR CHILD SUPPORT ENFORCE-CUSTD PARENT 918 kb 09/28/2018 Y
375 AUTHORIZATION TO TRANSFER BACKGROUND CHECK RESULTS 1288 kb 03/18/2021 Y
379 CORRECTION ORDER 1289 kb 02/02/2021 Y
383 SERIOUS ACCIDENT INJURY OR ILLNESS REPORT 935 kb 12/15/2020 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
393 MFCU CLINICAL CRITERIA 596 kb 04/09/2008 Y
394 CHILDREN WITH MEDICALLY FRAGILE NEEDS APPLICATION 424 kb 03/09/2018 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
410 AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICES 1006 kb 12/31/2020 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
423 KINSHIP CARE PLACEMENT 134 kb 06/12/2014 Y
424 KINSHIP CARE AGREEMENT 124 kb 06/12/2014 Y
427 NURSING HOME CENSUS DATA REPORT 95 kb 07/25/2017 Y
429 MEMO AGREEMENT TO ESTABLISH PROTECTIVE PAYMENTS 205 kb 08/17/2012 Y
433 CHILD ABUSE AND NEGLECT BACKGROUND INQUIRY 964 kb 01/20/2021 Y
438 INCIDENT REPORT 1294 kb 12/15/2020 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
451 ELIGIBILITY REPORT ON DISABILITY INCAPAS 620 kb 04/02/2015 Y
452 APPLICATION FOR A LICENSE TO OPERATE AN ASSISTED LIVING FACI 661 kb 11/16/2017 Y
455 PRESENT DANGER PLAN 908 kb 11/05/2020 Y
462 REQUEST FOR APPEAL OF THE CA/N ASSESSMENT DECISION 901 kb 12/26/2019 Y
465 REQUEST FOR GRIEVANCE MEETING TO REVIEWTHE CONDUCT OF CA/N A 54 kb 01/08/2010 Y
466 BACKGROUND CHECK ADDRESS DISCLOSURE 437 kb 09/09/2016 Y
467 PERSONAL AUTHORIZATION FOR CRIMINAL RECORD INQUIRY 463 kb 09/09/2016 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
481 SERVICE LIMITS SERVICE AUTHORIZATION REQUEST 470 kb 06/23/2020 Y
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
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
497 ALTERNATIVE RESPONSE SAFETY SUPPORT AGREEMENT 890 kb 10/23/2017 Y
501 HEALTH CARE COVERAGE REVIEW 624 kb 11/18/2016 Y
507 STEP ONE VOLUNTARY TREATMENT PROGRAM APPLICATION 709 kb 06/05/2015 Y
509 OUT OF STATE ENROLLMENT CLARIFICATION 197 kb 10/04/2018 Y
511 MEDICAL PROCEDURE/DEVICE SERVICE AUTHORIZATION REQUEST 506 kb 06/23/2020 Y
517 CHILD CARE EVACUATION DISASTER PLAN 481 kb 01/11/2017 Y
522 CERTIFICATE OF MEDICAL NECESSITY-SPEECH GENERATING DEVICE 402 kb 08/15/2019 Y
524 CERTIFICATE OF MEDICAL NECESSITY-CPAP/BIPAP 194 kb Y
526 CERTIFICATE OF MEDICAL NECESSITY-STANDING FRAMES 254 kb Y
527 GENETIC TESTING SERVICE AUTHORIZATION REQUEST 566 kb 07/14/2020 Y
528 CERTIFICATE OF MEDICAL NECESSITY-INFANT APNEA MONITOR 453 kb 08/25/2016 Y
529 APPLICATION: LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 1151 kb 10/20/2020 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
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
560 ASSIGNMENT OF BENEFITS 196 kb 09/08/2017 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
572 HEALTH INSURANCE QUESTIONNAIRE 1296 kb 03/04/2020 Y
573 RUNAWAY AND MISSING YOUTH SCREENING 1289 kb 02/27/2020 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
580 CERTIFICATE OF MEDICAL NECESSITY/CRANIAL REMOLDING ORTHOSIS 409 kb 08/25/2016 Y
581 CERTIFICATE OF MEDICAL NECESSITY/HEARING AIDS 412 kb 08/25/2016 Y
583 ND MEDICAID/ELECTRONIC REMITTANCE ADVICE (835) ENROLLMENT 903 kb 04/07/2021 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
605 INFORMED CLINICAL OPINION-ND EARLY INTERVENTION SYSTEM 893 kb 10/16/2020 Y
606 MEDICAID OUT OF STATE SERVICES CERTIFICATION 320 kb 02/27/2012 Y
614 PHYSICIAN CERTIFICATION FOR HYSTERECTOMY AND STERILIZATION 328 kb 10/30/2019 Y
615 MEDICAID PROGRAM PROVIDER AGREEMENT 369 kb 06/23/2020 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 03/18/2021 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
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
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
661 ELECTRONIC FUNDS TRANSFER (EFT) 350 kb 10/14/2020 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
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
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
708 PRIMARY CARE CASE MANAGMENT (PCCM) PROGRAM REFERRAL 334 kb 06/23/2020 Y
710 HEALTH TRACKS REFERRAL AND REQUEST FOR INFORMATION 296 kb 05/11/2020 Y
719 TANF REQUEST FOR BENEFITS 403 kb 08/17/2012 Y
720 CERTIFICATE OF MEDICAL NECESSITY MOTORIZED WHEELCHAIR 240 kb Y
722 CERTIFICATE OF MEDICAL NECESSITY OSTEOGENTIC STIMULATOR 239 kb Y
724 CERTIFICATE OF MEDICAL NECESSITYSEAT LIFT MECHANISM 217 kb Y
725 REQEUST FOR ACCOUNTING OF DISCLOSURES 381 kb 09/30/2013 Y
726 CERTIFICATE OF MEDICAL NECESSITY PARENTERAL NUTRITION 196 kb Y
727 CERTIFICATE OF MEDICAL NECESSITY SECTION C CONTINUATION 162 kb 10/18/2011 Y
728 CERTIFICATE OF MEDICAL NECESSITY SUPPORT SURFACES 252 kb Y
729 CERTIFICATE OF MEDICAL NECESSITY OXYGEN 237 kb Y
735 DIVERSION ASSISTANCE SCREENING TOOL 192 kb 08/17/2012 Y
736 CONTROLLED SUBSTANCE AGREEMENT 627 kb 11/22/2016 Y
739 AUTHORIZATION TO PROVIDE COMPANIONSHIP SERVICES 1359 kb 02/25/2021 Y
740 COMPANIONSHIP BILLING WORKSHEET 1290 kb 03/16/2021 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
750 DOCUMENTATION OF COMPETENCY 613 kb 10/29/2019 Y
763 REPORT OF TERMINATION OF ADOPTIVE PLACEMENT 168 kb Y
764 NOTICE OF INTENT TO PLACE DHS CUSTODY CHILD 193 kb Y
765 PAYPOINT PRE-AUTHORIZATION 166 kb Y
768 FUNDS MATCH CERTIFICATION 885 kb 02/24/2020 Y
769 REQUEST FOR SERVICE AUTHORIZATION OUT-OF STATE MED TREATME 617 kb 09/03/2014 Y
771 REPORT TO THE COURT 233 kb Y
780 CERTIFICATE OF MEDICAL NECESSITY EXTERNAL INFUSION PUMP 206 kb Y
781 CERTIFICATE OF MEDICAL NECESSITY MANUAL WHEELCHAIR 240 kb Y
782 CERTIFICATE OF MEDICAL NECESSITY ENTERAL NUTRITION 354 kb 01/28/2020 Y
785 CERTIFICATE OF MEDICAL NECESSITY HOSPITAL BEDS 237 kb Y
789 CERTIFICATE OF MEDICAL NECESSITY TENS 200 kb 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
800 FIRE SAFETY SELF DECLARATION FAMILY FOSTER CARE 1559 kb 09/27/2019 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
812 CHILD INTAKE RECORD 416 kb 04/13/2010 Y
814 REQUEST FOR BENEFICIARY SERVICE COVERAGE 306 kb 01/07/2020 Y
823 EVACUATION DISASTER PLAN-AGENCY/INDIVIDUAL FOSTER CARE 474 kb 12/06/2019 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
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
836 FINGERPRINT IDENTITY VERIFICATION 905 kb 12/29/2020 Y
839 FOSTER CARE OVERPAYMENT NOTIFICATION 932 kb 04/01/2021 Y
841 CHILD CARE ASSISTANCE PROGRAM REVIEW 1492 kb 03/01/2021 Y
842 PLACEMENT ACKNOWLEDGEMENT FAMILY FOSTER HOMES 910 kb 09/17/2019 Y
843 FOSTER CARE PROVIDER FINANICAL REPORT 974 kb 03/08/2021 Y
844 RELATIVE WAIVER FAMILY FOSTER HOMES 935 kb 09/17/2019 Y
845 CHILD INFORMATION SHEET 505 kb 02/05/2020 Y
846 RELEASE OF INFORMATION-CHILD CARE FACILITY 174 kb Y
847 PARENTS STATEMENT ON HEALTH OF CHILD 490 kb 07/26/2011 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
855 TITLE IV-E ADOPTION SUBSIDY ELIGIBILITY DETERMINATION 263 kb 03/03/2021 Y
859 SUBSTANCE ABUSE DISORDER VOUCHER PROGRAM APPLICATION 874 kb 05/06/2020 Y
863 LICENSING CHANGE CHECKLIST-FAMILY FOSTER HOMES 968 kb 03/11/2021 Y
865 APPLICATION FOR SELF-DECLARATION DOCUMENT 922 kb 01/21/2021 Y
875 FALSE CLAIMS EDUCATION CERTIFICATION 323 kb 01/10/2020 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 1008 kb 11/05/2020 Y
886 APPLICATION FOR CHILD PLACING AGENCY LICENSE 1208 kb 02/20/2013 Y
887 APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL) 1265 kb 09/16/2019 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
898 ANNUAL LICENSING APPLICATION QRTP 2292 kb 09/17/2019 Y
904 AGREEMENT TO FURNISH SPECIALIZED FAMILY FOSTER CARE SERVICES 913 kb 12/30/2020 Y
905 TECHNOLOGY/PROCEDURE ASSESSMENT 401 kb 12/18/2019 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
930 BACKGROUND INFORMATION FOR ADOPTION SERVICES 1.1 Mb Y
933 REQUEST FOR PRIVACY OFFICER REVIEW (HIPAA) 361 kb 09/30/2013 Y
934 REQUEST FOR INFORMAL PRIVACY CONFERENCE 361 kb 09/30/2013 Y
936 ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICE 87 kb Y
937 NOTICE OF PLACEMENT OF CHILD WITH IMMEDIATE RELATIVE 183 kb Y
939 REPORT OF ADOPTION/ADOPTIVE PLACEMENT 650 kb 05/21/2009 Y
940 SEARCH/DISCLOSURE REQUEST 644 kb 07/20/2018 Y
942 SEARCH/DISCLOSURE NOTIFICATION 184 kb Y
945 CERTIFICATION TO THE NORTH DAKOTA DEPT. OF HUMAN SERVICES 201 kb Y
946 AFFIDAVIT 167 kb Y
947 NOTICE OF INTENT/FINAL INTERNATIONAL ADOPTION DECREE 189 kb Y
948 NOTICE OF INTENT 222 kb 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
960 REPORT OF SUSPECTED CHILD ABUSE OR NEGLE 485 kb 06/02/2015 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
969 ORIENTATION CERTIFICATION 905 kb 02/04/2021 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
972 DECLARATION OF GOOD HEALTH 426 kb 09/16/2019 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
985 APPLICATION FOR ELIGIBILITY DETERMINATION 1056 kb 01/19/2021 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 974 kb 03/03/2021 Y
1010 PROVIDER ASSURANCE TO FEDERAL HOME & COMMUNITY BASED SERVICE 913 kb 10/16/2020 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
1033 AUTHORIZATION 430 kb 05/29/2014 Y
1041 CHILD CARE DEATH REPORT 930 kb 12/14/2020 Y
1042 IRREGULAR FOSTER CARE PAYMENTS 918 kb 02/16/2021 Y
1047 APPLICATION FOR SERVICE 888 kb 12/21/2018 Y
1059 AUTHORIZATION TO DISCLOSE INFORMATION 938 kb 12/02/2020 Y
1077 WORK ACTIVITY REPORT (SELF EMPLOYED PERSON) 255 kb Y
1078 WORK ACTIVITY REPORT-EMPLOYEE 410 kb Y
1081 DISCOVERY PROFILE 1363 kb 01/29/2020 Y
1084 NOTICE TO NDDHS * SPEC NEEDS ADOPTIVE PLACEMENT 203 kb 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
1105 MTM PROVIDER ENROLLMENT APPLICATION 320 kb 06/13/2018 Y
1106 MTM SERVICE AUTHORIZATION REQUEST 327 kb 05/06/2019 Y
1110 MTM MISSED APPOINTMENT 372 kb 03/22/2016 Y
1146 NON-PROFIT CLINIC DENTAL ACCESS PROJECT ACPPLICATION 311 kb 05/20/2020 Y
1150 EARLY CHILDHOOD SERVICES APPLICATION FOR WAIVER OF RATIO 911 kb 12/16/2020 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
1169 PHARMACY AGREEMENT 447 kb 03/19/2018 Y
1177 REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS 1039 kb 02/09/2021 Y
1235 VISITOR SIGN-IN LOG 1285 kb 01/28/2020 Y
1257 COMPLIANCE CHECK LIST/SCHOOL AGE CHILD CARE CENTER 2642 kb 10/10/2016 Y
1258 CHILD CARE FACILITY STAFFING 1175 kb 01/12/2018 Y
1259 CHILD CARE PROVIDER STAFFING 1289 kb 12/02/2020 Y
1269 CHILD CARE CONCERN 916 kb 02/04/2021 Y
1276 EARLY CHILDHOOD SERVICES REVIEW 1523 kb 02/13/2018 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
1415 ND MEDICAL ACUITY TIER RATE ADD-ON SECONDARY ASSESSMENT 2600 kb 10/16/2020 Y
1422 COMPLIANCE CHECK LIST/FAMILY CHILD CARE HOMES 2704 kb 06/20/2018 Y
1423 COMPLIANCE CHECKLIST/CHILD CARE CENTER 3830 kb 10/07/2016 Y
1424 COMPLIANCE CHECKLIST PRESCHOOL EDUCATIONAL FACILITIES 2949 kb 08/30/2018 Y
1425 COMPLIANCE CHECKLIST/GROUP CHILD CARE 3821 kb 06/20/2018 Y
1426 CHILD CARE RECORD 449 kb 10/06/2016 Y
1467 SPED EXSPED INDIVIDUAL CARE PLAN 935 kb 01/29/2019 Y
1508 PRIMARY CARE ENHANCED PAYMENT INCREASE SELF-ATTESTATION 665 kb 05/22/2013 Y
1510 OTOACOUSTIC EMISSIONS TYMPANOMETRY (OAE/TYMP) SCREENING 896 kb 09/23/2020 Y
1525 SITUATIONAL ASSESSMENT REPORT 1364 kb 12/18/2019 Y
1544 POLICIES AND PROCEDURES CHECKLIST 902 kb 09/23/2020 Y
1545 SANITATION INSPECTION CERTIFICATION 896 kb 10/26/2020 Y
1549 GOVERNANCE STATEMENT 896 kb 09/24/2020 Y
1550 LICENSE TERMINATION REQUEST 1285 kb 10/16/2020 Y
1551 LICENSE APPLICATION CHECKLIST/RESIDENTIAL SERVICES 176 kb Y
1552 LICENSE APPLICATION CHECKLIST/DAY SERVICES 176 kb Y
1555 PHYSICAL STANDARDS CHECKLIST - GROUP HOME FACILITIES 1092 kb 11/09/2020 Y
1556 PLAN OF CORRECTION 894 kb 09/30/2020 Y
1557 DD PROGRAM ADMIN/PROGRAM MANAGER ENVIRONMENTAL SCAN CHECKLIS 2071 kb 01/31/2020 Y
1560 DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY 909 kb 02/17/2021 Y
1595 SELF-DECLARATION PROVIDER REVIEW 485 kb 12/17/2013 Y
1597 EXPLANATION OF CLIENT CHOICE 903 kb 05/12/2020 Y
1598 MEDICALLY FRAIL QUESTIONNAIRE 2094 kb 01/30/2018 Y
1603 INDIVIDUAL REQUEST TO BE A QUALIFIED SERVICE PROVIDER 1574 kb 12/07/2020 Y
1604 REQUEST TO BE A QSP FOR FAMILY HOME CARE 1302 kb 12/20/2018 Y
1605 INDIVIDUAL REQUEST TO BE A QSP/AFC PROVIDER 984 kb 01/03/2019 Y
1606 AGENCY REQUEST TO BE A QUALIFIED SERVICE PROVIDER 1658 kb 05/15/2020 Y
1607 RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT 1241 kb 06/29/2020 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
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
1694 SEARCH AND COPYING SERVICES RECORDS REQUEST 162 kb Y
1699 AUTHORIZATION TO PROVIDE SERVICES FOR SPED/EXSPED 329 kb 04/24/2019 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
1763 REQUEST FOR REIMBURSEMENT/DIRECT SERVICE 717 kb 11/13/2020 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
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
1808 SIS & ICAP ASSESSMENT PROTOCOLCHECKLIST 977 kb 10/22/2020 Y
1810 AUTHORIZATION TO PROVIDE DEVELOPMENTAL DISABILITIES SERVICES 977 kb 01/14/2021 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
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
1862 COMMUNITY TRANSITION SERVICES BUDGET TRAD IID/DD WAIVER 1289 kb 10/16/2020 Y
1870 DUI SEMINAR INSTRUCTOR CERTIFICATION/RECERT APPLICATION 913 kb 10/12/2017 Y
1907 EARLY CHILDHOOD INCLUSION SUPPORT GRANT APPLICATION 364 kb 05/26/2017 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
1948 IRS SAFEGUARD REVIEW REPORT 1046 kb 03/22/2019 Y
1967 OPT OUT OF MAKING INCOME WITHHOLDING PYMTS ELECTRONICALLY 275 kb 04/22/2014 Y
1968 SPECIAL DIFF ASSOCIATION WITH MAKING INCOME WITHOLD ELECT 310 kb 11/13/2014 Y
1969 SPECIAL DIFF WITH REPORTING NEW HIRES ELECTRONICALLY 309 kb 04/22/2014 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 963 kb 02/01/2021 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
1980 REQUEST TO RESTRICT USE & DISCLOSURE OF PHI 509 kb 09/30/2013 Y
1981 REQUEST TO AMEND RECORDS-PHI 451 kb 07/13/2017 Y
1992 RELEASE OF INFORMATION - ADOPTION DISCLOSURE 623 kb 04/11/2016 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