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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 634 kb 07/25/2017 Y
15 HOME HEALTH EXTENDED HOME HEALTH REQUEST FOR SERV AUTHORIZAT 267 kb 09/03/2014 Y
20 SUSPECTED FRAUD REFERRAL 537 kb 05/02/2017 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
43 NATIONAL PROVIDER IDENTIFIER REGISTRATION 226 kb Y
49 CHILD CARE ASSISTANCE PROGRAM DIRECT DEPOSIT BANKING INFO 1079 kb 02/10/2016 Y
52 SPOUSAL ASSETS 505 kb 08/17/2012 Y
53 CHILDREN'S HOSPICE PERSON-CENTERED CARE PLAN 565 kb 02/03/2017 Y
55 STATEMENT ACTUAL COSTS-IN HOME SEVICE 78 kb N
56 EXSPED PROGRAM DATA 640 kb 10/27/2016 Y
61 HEALTH TRACKS COMPREHENSIVE ORTHODONTIC SCREENING 508 kb 01/25/2013 Y
62 EMERGENCY ASSISTANCE APPLICATION 326 kb Y
64 RQUEST FOR EXTRA TIME INDIVIDUALS WITH DEVELOPMENTAL DISABIL 347 kb 05/01/2017 Y
73 PRTIAL HOSPITALIZATION PRIOR (PHP) SERVICE AUTH/CONT STAY 604 kb 09/09/2015 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
107 SOCIAL/EMOTIONAL/DEVELOPMENTAL WELL-BEING SCREENING-PREMILIN 339 kb Y
113 POST SECONDARY EDUCATION INFORMATION 336 kb 02/08/2013 Y
114 NURSING FACILITY REQUEST FOR STATE RETRO LEVEL OF CARE REVIE 257 kb 04/26/2010 Y
116 QUALITY ASSURANCE CHECKLIST-EARLY CHILDHOOD SERVICES 439 kb 06/07/2016 Y
128 ND FAMILY CAREGIVER SUPPORT PROGRAM PROVIDER AGREEMENT 1393 kb 05/15/2017 Y
129 ALTERNATIVE TO ABORTION SERVICES PAYMENT VOUCHER 602 kb 12/28/2010 Y
132 PHYSICIAN STATEMENT FOR MEDICAID TEMPORARY STAY REVIEW 334 kb 06/11/2015 Y
135 ND FAMILY CAREGIVER SUPPORT PROVIDER SERV LOG-INDIVIDUAL 470 kb 05/25/2017 Y
136 PLAN OF CORRECTION HCBS SURVEY 1010 kb 01/05/2017 Y
143 CIVIL RIGHTS COMPLAINT 418 kb 02/04/2016 N
152 CHILD SUPPORT VERIFICATION 108 kb Y
161 DIRECT DEPOSIT ENROLLMENT AND AUTHORIZATION 269 kb 08/18/2010 Y
162 REQUEST FOR HEARING 389 kb 06/09/2015 Y
167 DETERMINATION OF AVAILABLITY OF EMPLOYER-BASED HEATLH INSURA 276 kb 08/17/2012 Y
168 ND MEDICAID PROVIDER APPEAL 359 kb 07/31/2015 Y
171 FOSTER PROGRAM SUBSIDIZED EMPLOYMENT AGREEMENT 247 kb 02/03/2010 Y
177 MMIS ATTACHMENT COVER SHEET 362 kb 08/31/2015 Y
200 ASSET ASSESSMENT 1096 kb 03/08/2017 Y
205 ANNUAL LICENSING APPLICATION - PRTF 1349 kb 02/07/2013 Y
209 CHILDCARE FACILITY FIRE DRILL RECORD 225 kb Y
212 RURAL DIFFERENTIAL CLOSURE 388 kb 10/31/2016 Y
223 FIRE INSPECTION CERTIFICATION 214 kb Y
224 PRIVATE DUTY NURSING SERVICE AUTHORIZATION 422 kb 09/03/2014 Y
228 WORKING DISABILITY REPORT 482 kb 08/17/2012 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
234 INSURANCE COVERAGE 197 kb Y
235 CRIMINAL OFFENSE 197 kb Y
236 FINANCIAL DISCLOSURE 161 kb Y
247 MDS APPEALS REQUEST 386 kb 09/19/2014 Y
252 CFCIP ND EDUCATION OF TRAINING VOUCHER PROGRAM (ETV) 901 kb 08/22/2013 Y
255 INDEPENDENT LIVING AGREEMENT 326 kb 12/28/2010 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 570 kb 09/02/2015 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 176 kb 10/16/2007 Y
328 FAMILY FOSTER CARE HOME PROP DAMAGE VERIFICATION OF CLAIM 495 kb 06/20/2013 Y
343 CHILD CARE TRAINING DOCUMENTATION 573 kb 12/17/2013 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
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
377 CRIMINAL HISTORY BACKGRUOND CHECK ADDRESS RELEASE OF INFO 478 kb 08/05/2011 Y
383 SERIOUS ACCIDENT INJURY OR ILLNESS REPORT 592 kb 11/05/2012 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
393 MFCU CLINICAL CRITERIA 596 kb 04/09/2008 Y
394 CHILDREN WITH MEDICALLY FRAGILE NEEDS APPLICATION 430 kb 12/09/2014 Y
400 ANNUAL APPLICATION TO PROVIDE FAMILY FOSTER CARE 721 kb 09/23/2016 Y
404 PERSON CENTERED PLAN OF CARE 1740 kb 10/31/2016 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 163 kb 08/17/2012 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 476 kb 11/08/2016 Y
438 INCIDENT REPORT FORM 809 kb 06/20/2014 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
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 07/05/2017 Y
462 REQUEST FOR APPEAL OF THE CN/A ASSESSMENT DECISION 315 kb 09/27/2016 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 AFDC AUTH AND REQUEST FOR PYMT OF GOODS & SER 449 kb 08/17/2012 Y
481 SERVICE LIMITS SERVICE AUTHORIZATION REQUEST 467 kb 04/19/2017 Y
492 ND FAMILY CAREGIVER SUPPORT PROG PROVIDER SERVICE LOG-AGENCY 473 kb 05/25/2017 Y
494 FOSTER CARE YOUTH TRANSITION CHECKLIST 1002 kb 09/17/2015 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
508 AUTHORIZATION FOR BACKGROUND CHECK 460 kb 01/27/2017 Y
509 OUT OF STATE ENROLLMENT CLARIFICATION 174 kb 07/25/2017 Y
511 MEDICAL PROCEDURE/DEVICE SERVICE AUTHORIZATION REQUEST 440 kb 07/11/2017 Y
517 CHILD CARE EVACUATION DISASTER PLAN 481 kb 01/11/2017 Y
522 CERTIFICATE OF MEDICAL NECESSITY-SPEECH GENERATING DEVICE 223 kb Y
524 CERTIFICATE OF MEDICAL NECESSITY-CPAP/BIPAP 194 kb Y
526 CERTIFICATE OF MEDICAL NECESSITY-STANDING FRAMES 254 kb Y
528 CERTIFICATE OF MEDICAL NECESSITY-INFANT APNEA MONITOR 453 kb 08/25/2016 Y
529 APPLICATION ENERGY ASSISTANCE PROGRAM 1627 kb 07/26/2016 Y
560 ASSIGNMENT OF BENEFITS 197 kb 08/17/2012 Y
566 MEDICAID QUESTIONNAIRE AND ASSIGNMENT 744 kb 09/03/2015 Y
573 RUNAWAY AND MISSING YOUTH SCREENING 448 kb 09/17/2015 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
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 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
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 1760 kb 10/31/2016 Y
599 PRTF LICENSURE/REQUEST FOR CHANGE IN BED CAPACITY APPLICATIO 508 kb 06/05/2015 Y
606 MEDICAID OUT OF STATE SERVICES CERTIFICATION 320 kb 02/27/2012 Y
614 PHYSICIAN CERTIFICATION FOR STERILIZATION 261 kb 10/20/2008 N
615 MEDICAID PROGRAM PROVIDER AGREEMENT 448 kb 08/08/2017 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 PROVIDER AGREEMENT 1676 kb 07/25/2017 Y
630 FOSTER CARE PLACEMENT NOTIFICATION & PRELIM ELIGIBLITY DET 868 kb 05/01/2015 Y
634 CLAIM FORM DRUG PHARMACY 140 kb Y
641 TITLE IV-E/TITLE XIX APPLICATION - FOSTER CARE 2249 kb 04/19/2017 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
659 RESPITE HOME EVALUATION 516 kb 11/02/2016 Y
661 ELECTRONIC FUNDS TRANSFER (EFT) 271 kb 07/25/2017 Y
688 ASSISTIVE TECHNOLOGY REQUEST - ASD WAIVER ONLY 413 kb 05/17/2017 Y
690 AFFIDAVIT OF IDENTITY-DISABILED INDIVIDUAL IN FACILITY 189 kb 08/17/2012 Y
691 AFFIDAVIT OF IDENTITY-for children 258 kb 08/17/2012 Y
705 HEALTH TRACKS APPOINTMENT SLIP 289 kb 01/28/2013 Y
706 AFFIDAVIT OF EXPLANATION WHY CITIZENSHIP VERIFY NOT SUPPLIED 184 kb 08/17/2012 Y
707 CITIZENSHIP AFFIDAVIT 290 kb 08/17/2012 Y
708 PRIMARY CARE CASE MANAGMENT (PCCM) PROGRAM REFERRAL 395 kb 03/15/2016 Y
710 HEALTH TRACKS REFERRAL AND REQUEST FOR INFORMATION 48 kb 08/17/2012 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
743 CHILDRENS' HOSPICE WAIVER APPLICATION 310 kb 08/17/2012 Y
747 ADULT FOSTER CARE APPEAL 631 kb 03/09/2017 Y
750 DOCUMENTATION OF COMPENTENCY 970 kb 12/08/2014 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
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 ORAL &/OR EXT NUTRITION 396 kb 04/17/2012 Y
783 SUBSTANCE USE DISORDER (SUD) VOUCHER INDIVIDUAL APPLICATION 728 kb 06/26/2017 Y
784 SUD VOUCHER PRIOR AUTHORIZATION/CONTINUED STAY 1019 kb 07/28/2017 Y
785 CERTIFICATE OF MEDICAL NECESSITY HOSPITAL BEDS 237 kb Y
787 SUD VOUCHER EXCEPTION REQUEST 1087 kb 10/12/2016 Y
789 CERTIFICATE OF MEDICAL NECESSITY TENS 200 kb Y
792 OPIOD TREATMENT PROGRAM FEDERAL EXEMPTION REQUEST 659 kb 11/15/2016 Y
800 FIRE SAFETY SELF DECLARATION 545 kb 03/12/2013 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
812 CHILD INTAKE RECORD 416 kb 04/13/2010 Y
823 EVACUATION DISASTER PLAN-ADULT FOSTER CARE 475 kb 03/29/2017 Y
824 UNIVERSAL APPLICATION 2544 kb 07/06/2010 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 08/23/2016 Y
832 APPLICATION TO BE LICENSED 684 kb 06/07/2016 Y
838 PERSONAL AUTHOR FOR CRIM HISTORY BACKGROUND CHECK INQUIRY 616 kb 08/26/2016 Y
841 CHILD CARE ASSISTANCE PROGRAM REVIEW 1468 kb 10/27/2016 Y
845 CHILD INFORMATION SHEET 507 kb 12/17/2013 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
859 SUBSTANCE ABUSE DISORDER VOUCHER PROGRAM APPLICATION 1346 kb 06/29/2017 Y
865 APPLICATION FOR SELF-DECLARATION DOCUMENT 532 kb 01/11/2017 Y
874 OFFICIAL REQUEST FOR CUSTOMER FINANCIAL RECORDS 1062 kb 04/19/2017 Y
875 FALSE CLAIMS EDUCATION CERTIFICATION 235 kb 07/25/2017 Y
878 CROSSROADS EVALUATION (CASE MANAGER) 642 kb 10/31/2014 Y
879 CROSSROAD EVALUATION (SCHOOL) 520 kb 10/31/2014 Y
886 APPLICATION FOR CHILD PLACING AGENCY LICENSE 1208 kb 02/20/2013 Y
890 AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO 416 kb 08/23/2016 Y
898 ANNUAL LICENSING APPLICATION RCCF 2486 kb 10/22/2013 Y
904 AGREEMENT TO FURNISH SPECIALIZED FAMILY FOSTER CARE SERVICES 363 kb 04/10/2015 Y
905 TECHNOLOGY/PROCEDURE ASSESSMENT 284 kb 03/30/2010 Y
918 SERVICE MANAGEMENT LOG 413 kb 07/07/2017 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 BACKGROUND INFORMATION REQUEST AUTHORIZATION 330 kb 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 06/07/2017 Y
958 HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED 2053 kb 05/01/2017 Y
960 REPORT OF SUSPECTED CHILD ABUSE OR NEGLE 485 kb 06/02/2015 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
969 ORIENTATION CERTIFICATION 434 kb 06/07/2016 Y
970 MULTI-AGENCY AUTHORIZATION TO DISCLOSE INFORMATION 329 kb 04/10/2014 Y
971 SUBSTANCE ABUSE TREATMENT LICENSE APPLICATION 579 kb 06/05/2015 Y
972 DECLARATION OF GOOD HEALTH 296 kb 09/27/2010 Y
980 INDIVIDUAL REQUEST TO BE A QSP/AFFC PROVICER 579 kb 11/01/2012 Y
981 REQUEST/AUTHORIZATION BY APPLICANT FOR COPY OF FBI REPORT 380 kb 11/07/2014 Y
989 STERILIZATION CONSENT FORM 127 kb Y
991 MEDICAID PAYMENT ALERT 405 kb 08/01/2017 Y
1018 NEW HIRE REPORTING 707 kb 11/17/2015 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 518 kb 06/12/2012 Y
1047 APPLICATION FOR SERVICES 182 kb Y
1059 AUTHORIZATION TO DISCLOSE INFORMATION 129 kb 08/17/2012 Y
1077 WORK ACTIVITY REPORT (SELF EMPLOYED PERSON) 255 kb Y
1078 WORK ACTIVITY REPORT-EMPLOYEE 410 kb Y
1084 NOTICE TO NDDHS * SPEC NEEDS ADOPTIVE PLACEMENT 203 kb Y
1105 MTM PHARMACIST ENROLLMENT APPLICATION 381 kb 04/20/2016 Y
1106 MTM SERVICE AUTHORIZATION REQUEST 358 kb 03/22/2016 Y
1107 MTM INTERVENTIONS ON MEDICATION RELATED PROBLEMS 571 kb 04/04/2016 Y
1108 ND MEDICAID (MTM) INITIAL VISIT/PRESCRIBER SUMMARY COVER 393 kb 03/22/2016 Y
1109 ND MEDICAID (MTM) SUBSEQUENT VISIT/PRESCRIBER SUMMARY COVER 386 kb 03/22/2016 Y
1110 MTM MISSED APPOINTMENT 372 kb 03/22/2016 Y
1111 MTM CONSULTATION 702 kb 03/22/2016 Y
1125 EXTENDED SERVICES MONTHLY PROGRESS SUMMARY 858 kb 01/10/2012 Y
1130 HOUR BY HOUR STAFFING SCHEDULE FOR GROUP CHILD CARE 1287 kb 09/21/2011 Y
1146 NONPROFIT CLINIC DENTAL ACCESS PROJECT ACPPLICATION 343 kb 08/26/2013 Y
1150 EARLY CHILDHOOD SERVICES APPLICATION FOR WAIVER OF RATIO 358 kb 08/31/2012 Y
1168 OWNERSHIP CONTROLLING INTEREST AND CONVICTION INFORMATION 1280 kb 07/25/2017 Y
1169 PHARMACY AGREEMENT 368 kb 07/25/2017 Y
1177 REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS 838 kb 02/06/2017 Y
1224 MEDICAL/CHILD SUPPORT QUESTIONNAIRE 248 kb Y
1257 COMPLIANCE CHECK LIST/SCHOOL AGE CHILD CARE CENTER 2642 kb 10/10/2016 Y
1258 CHILD CARE FACILITY STAFFING 673 kb 01/11/2017 Y
1259 CHILD CARE PROVIDER STAFFING 650 kb 01/11/2017 Y
1269 CHILD CARE CONCERN FORM 601 kb 12/17/2013 Y
1276 EARLY CHILDHOOD SERVICES REVIEW FORM 1551 kb 01/12/2017 Y
1296 CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES 699 kb 04/06/2017 Y
1330 REQUEST TO ADD AN AFFILIATION 405 kb 07/25/2017 Y
1331 PROVIDER TERMINATION 436 kb 08/08/2017 Y
1422 COMPLIANCE CHECK LIST/FAMILY CHILD CARE HOMES 2684 kb 10/07/2016 Y
1423 COMPLIANCE CHECKLIST/CHILD CARE CENTER 3830 kb 10/07/2016 Y
1424 COMPLIANCE CHECKLIST PRESCHOOL ECUCATIONAL FACILITIES 2898 kb 10/07/2016 Y
1425 COMPLIANCE CHECKLIST/GROUP CHILD CARE 3798 kb 10/07/2016 Y
1426 CHILD CARE RECORD 449 kb 10/06/2016 Y
1467 INDIVIDUAL CARE PLAN 623 kb 11/22/2016 Y
1508 PRIMARY CARE ENHANCED PAYMENT INCREASE SELF-ATTESTATION 665 kb 05/22/2013 Y
1510 OAE/TYMP SCREENING 367 kb 09/17/2014 Y
1544 POLICIES AND PROCEDURES CHECKLIST 190 kb Y
1545 SANITATION INSPECTION CERTIFICATION 212 kb Y
1546 LICENSE APPLICATION/RESIDENTIAL SERVICES 512 kb 11/29/2016 Y
1547 LICENSE APPLICATION/DAY SERVICES 477 kb 11/29/2016 Y
1549 GOVERNANCE STATEMENT 196 kb Y
1550 LICENSE TERMINATION REQUEST 184 kb Y
1551 LICENSE APPLICATION CHECKLIST/RESIDENTIAL SERVICES 176 kb Y
1552 LICENSE APPLICATION CHECKLIST/DAY SERVICES 176 kb Y
1555 PHYSICAL STANDARDS CHECKLIST 346 kb Y
1556 PLAN OF CORRECTION 159 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
1595 SELF-DECLARATION PROVIDER REVIEW 485 kb 12/17/2013 Y
1598 MEDICALLY FRAIL QUESTIONNAIRE 1655 kb 08/03/2017 Y
1601 GROUP PROVIDER ENROLLMENT APPLICATION 2899 kb 07/25/2017 Y
1602 INDIVIDUAL PROVIDER ENROLLMENT APPLICATION 1799 kb 07/25/2017 Y
1603 ADDL SERVICE LOCATION: REQUEST TO BE A QUALIFIED PROVIDER 1605 kb 12/08/2015 Y
1604 REQUEST TO BE A QSP FOR FAMILY HOME CARE 1284 kb 04/14/2016 Y
1605 INDIVIDUAL REQUEST TO BE A QSP/AFC PROVIDER 1552 kb 03/08/2017 Y
1606 AGENCY REQUEST TO BE A QUALIFIED SERVICE PROVIDER 1763 kb 07/25/2017 Y
1607 RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT 1558 kb 01/19/2017 Y
1612 FOSTER CARE VERIFICATION 193 kb 01/09/2017 Y
1613 ND CHAFEE FOSTER CARE PROG/CURRENT FOSTER CARE YOUTH REFERRR 465 kb 03/24/2015 Y
1614 ND CHAFEE FOSTER CARE PROG/FOSTER CARE ALUMNI REFERRAL 605 kb 03/24/2015 Y
1618 HEALTH COVERAGE FROM JOBS 665 kb 08/30/2013 Y
1694 SEARCH AND COPYING SERVICES RECORDS REQUEST 162 kb 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
1763 REQUEST FOR REIMBURSEMENT/DIRECT SERVICE 650 kb 02/08/2017 Y
1765 REQUEST FOR REIMBURSEMENT/NON STATE 632 kb 02/19/2015 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
1829 LONG TERM CARE OMBUDSMAN PROGRAM COMPLAINT INTAKE 1013 kb 05/04/2016 Y
1853 REQUEST FOR REHAB SERVICES FOR MEDICAID ENROLLEES 351 kb 11/30/2012 Y
1870 DUI SEMINAR INSTRUCTOR CERTIFICATION APPLICATION 395 kb 06/05/2015 Y
1871 ASSURANCE OF COMPLIANCE 312 kb 06/05/2015 Y
1907 EARLY CHILDHOOD INCLUSION SUPPORT GRANT APPLICATION 364 kb 05/26/2017 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
1948 IRS SAFEGUARD REVIEW 901 kb 05/31/2017 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
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
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
59529 DHS EMPLOYEE CULTURAL AWARENESS SURVEY 997 kb 05/17/2011 Y
60600 PARTICIPANT SERVICE PLAN CHECKLIST (0-3) 1283 kb 06/25/2014 Y
60601 PARTICIPANT SERVICE PLAN CHECKLIST (3-18) 1204 kb 06/25/2014 Y
60602 REGISTRATION INTAKE SHEET 1519 kb 06/27/2014 Y
60603 GENERAL INCIDENT REPORT 1170 kb 02/15/2017 Y
60610 WITNESS ENTRY-RESTRATIN 523 kb 06/25/2014 Y
60611 APPLICATION FOR AUTISM VOUCHER 674 kb 05/23/2017 Y
60612 PROGRESS NOTES: SERVICE MANAGERS 449 kb 06/25/2014 Y
60613 PROGRESS NOTES: SKILLS TRAINERS 568 kb 06/25/2014 Y
60614 PROGRESS NOTES: SKILLS TRAINERS 449 kb 06/25/2014 Y
60615 TRANSITION PLAN OFF OF THE AUTISM WAIVER 342 kb 06/25/2014 Y
60616 PDM BEHAVIOR PLAN 454 kb 06/25/2014 Y
60617 PROGRAM DESIGN AND MONITORING REPORT 450 kb 06/25/2014 Y
60618 ND AUTISM WAIVER APPLIATION 546 kb 07/13/2017 Y
60619 WAIVER APPLICATION CASE ACTION REPORT 446 kb 06/25/2014 Y
60620 MMIS AUTHORIZATION-AUTISM WAIVER 504 kb 02/02/2015 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