Forms

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Department of Human Services - Internal Form(s)

SFNTitleSizeDateFillable
3 EBT Second Party Review Report 346 kb 12/11/2012
Y
11 Emergency Assistance Action Plan 208 kb
N
20 Surveillance & Utilization Review Section (SURS) Referral 360 kb 04/04/2013
Y
21 Transmittal Between Units 506 kb 09/14/2011
Y
23 Application For Approval For Relative Child Care Provider 630 kb 04/09/2014
Y
29 Crossroads Program Application 468 kb 08/17/2012
Y
37 Authorization for Services or Material 450 kb 08/06/2013
Y
38 Emergency Assistance Service Application 206 kb
Y
45 Notice of Change 379 kb 10/30/2012
Y
51 Authorization for County Employee Travel Reimbursement 821 kb 03/01/2010
Y
52 Spousal Assets 505 kb 08/17/2012
Y
56 Expanded SPED Program Data 192 kb 04/16/2010
Y
60 18+ Continued Foster Care Agreement 353 kb 12/16/2011
Y
61 Public 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
66 Public Health Tracks Interactive Orthodontic Screening 222 kb 08/17/2012
Y
75 Miscellaneous Payment Worksheet 273 kb
Y
76 Fixed Assets Data Entry 361 kb 11/04/2008
Y
78 Request for Purchase 541 kb 11/13/2013
Y
81 Designated Medical Provider 369 kb 09/11/2012
Y
91 Revocation of Authorization to Disclose Information 340 kb 09/30/2013
Y
98 Case Management Inter-Agency Referral Form 178 kb
Y
101 Grant Opportunity-Approval to Apply 367 kb 02/06/2012
Y
113 Postsecondary Education Information 336 kb 02/08/2013
Y
128 North Dakota Family Caregiver Support Program Provider Agreement 343 kb 03/29/2011
Y
143 Civil Rights Complaint 905 kb 10/14/2013
N
150 60-Month Lifetime Exemption Background Report 175 kb
Y
152 Child Support Verification 108 kb
Y
162 Request for Hearing 366 kb 08/17/2012
Y
165 Caregiver Option Plan 347 kb 05/01/2009
Y
167 Determination of Availability of Employer-Based Health Insurance 276 kb 08/17/2012
Y
170 Taxi Transportation Voucher 263 kb
Y
171 Foster Program Subsidized Employment Agreement 247 kb 02/03/2010
Y
187 Medical Expense Worksheet 407 kb 08/09/2010
Y
196 Ability to Pay - Fee Action Request 468 kb 09/21/2011
Y
200 Asset Assessment 272 kb 08/17/2012
Y
201 CBCU Trnasmittal Worksheet 539 kb 01/14/2014
Y
202 Group Homes and Drug/Alcohol Treatment Centers Monthly Listing 345 kb 10/08/2012
Y
208 Card Problem Report 419 kb 12/02/2013
Y
225 NDFCSP Rural Differential Unit Rate Authorization 408 kb 02/10/2014
Y
228 Workers with Disabilities Report-Part II 482 kb 08/17/2012
Y
244 Purchase Card Confirmation 288 kb 10/29/2009
Y
270 Request for Replacement Due to Loss of Food Purchased with Snap Benefits 341 kb 08/17/2012
Y
293 SNAP Program Negative Case Review 410 kb 08/13/2012
Y
298 Protective Service Alert Report 171 kb
Y
302 Authorization and Request for Payment 419 kb 11/29/2012
Y
307 Request for Safety/Permanency Funds 326 kb 01/26/2009
Y
319 Monthly EBT Inventory Control 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 306 kb 11/13/2012
Y
337 Supplemental Nutrition Assistance Program Claim Review 654 kb 04/24/2013
Y
338 Child Care Checklist 660 kb 04/22/2014
Y
339 Monthly Case Management Billing & Reporting Form 359 kb 12/26/2007
Y
348 Reasons for Filing a Petition to Terminate Parental Rights 185 kb
Y
353 Affidavit for Best Registrants 320 kb 08/17/2012
Y
362 SNAP Computation Sheet 356 kb 06/29/2012
Y
369 Application for Family Therapy-Intensive 786 kb 10/22/2010
Y
375 Notice of Assignment of Support Rights-Foster Care 141 kb 08/09/2010
Y
376 Drug-Related Felony Review 337 kb 03/13/2012
Y
379 Correction Order 393 kb 05/02/2013
Y
380 Unlicensed Child Care Provider Affidavit 350 kb 07/01/2011
Y
382 Child Care Licensing Letter 302 kb 04/10/2012
Y
384 SNAP Quarterly Report of Fraud Control Activities 332 kb 10/03/2012
Y
385 Affidavit for Work Registrants 318 kb 08/17/2012
Y
387 ICPC Supervision Report 248 kb 02/26/2009
Y
394 Children with Medically Fragile Needs Application 246 kb 08/17/2012
Y
395 ICPC Financial and Medical Plan 102 kb
Y
407 Monthly Report 318 kb 02/25/2014
N
408 Request for Non-State Employee to Operate State Vehicle 226 kb
Y
411 Aid to the Blind/Remedial-Denial Notice 313 kb 04/17/2012
Y
412 Aid to the Blind/Remedial-Approval Notice 399 kb 11/13/2013
Y
413 Individual Indian Monies Account 400 kb 07/25/2012
Y
414 Subsidized Employement Agreement 273 kb 08/17/2012
Y
416 Medicaid Application - Women's Way 163 kb 08/17/2012
Y
417 Reconciliation with Inventory Records 224 kb 08/09/2010
Y
419 Request to Division of Vital Statistics for Confidential Verification of Birth 89 kb
Y
420 Request to Division of Vital Statistics for Confidential 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 110 kb
Y
426 Kinship Care Study 1220 kb 01/14/2008
Y
429 Memorandum Of Agreement To Establish Protective Payments 205 kb 08/17/2012
Y
433 Child Abuse and Neglect Background Inquiry 283 kb 08/17/2012
Y
440 Child Care Review Error Case Findings 392 kb 04/09/2014
Y
443 Notice of Right to Claim "Good Cause" 111 kb 08/21/2012
Y
445 Family Evacuation Disaster Plan 333 kb 04/28/2011
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/Incapacity 485 kb 09/19/2012
Y
455 Safety/Strength/Risk Assessment 106 kb
Y
471 Vendor Payment (TANF) Authorization and Request For Payment For Goods and Services 449 kb 08/17/2012
Y
474 HCBS Case Closure/Transfer Notice 168 kb
Y
488 SNAP Case Review 690 kb 08/13/2012
Y
496 Child Protection Services Case Review 653 kb 10/19/2009
Y
499 Affidavit of Mailing 286 kb 01/05/2012
Y
500 SNAP Targeted Case Review 750 kb 09/13/2012
Y
507 Step One: Voluntary Treatment Program Application 676 kb
Y
529 Application: Heating Assistance Program 1646 kb 07/13/2011
Y
530 Eligibility and Benefit Worksheet 232 kb
N
540 Confidential Report of Job Service Unemployment Insurance 260 kb
Y
549 Respite Home Evaluation 298 kb
Y
559 Recipient Explanation of Medical Benefits 197 kb 03/17/2008
Y
560 Assignment of Benefits 197 kb 08/17/2012
Y
566 Medicaid Questionnaire and Assignment 501 kb 04/04/2013
Y
574 Professional Development/Training Request 340 kb 02/19/2013
Y
598 Child Care Assistance Application 1944 kb 08/07/2013
Y
616 Child Care Billing Report 946 kb 08/17/2012
Y
630 Foster Care Placement Notification & Preliminary Eligibility Determination 523 kb 04/29/2013
Y
641 Title IV-E Title XIX Application-Foster Care 635 kb 08/17/2012
Y
642 Title IV-E Title XIX Redetermination-Foster Care 157 kb
Y
655 LIHEAP - Case Review 821 kb 06/18/2012
Y
659 Respite Home Evaluation 295 kb
Y
662 Personal Care Plan 676 kb 04/22/2014
Y
663 Authorization to Provide Personal Care Services 486 kb 11/26/2013
Y
669 Initial Licensing Study-Adult Family Foster Care 1104 kb 06/23/2008
N
670 Child Care Assistance Change Report 744 kb 08/01/2013
Y
676 Add New Record to MMIS Eligibility File SPED 235 kb
N
677 Add New Record to MMIS Eligibility File - Expanded SPED 234 kb 01/06/2014
Y
679 Employment Communication Orientation Referral 389 kb 09/03/2013
Y
687 Medicaid Budget Worksheet 257 kb
Y
690 Affidavit of Identity for Disabled Individual in Facility 189 kb 08/17/2012
Y
691 Affidavit of Identity For Children 258 kb 08/17/2012
Y
700 Case Transfer Log 541 kb 06/19/2013
Y
701 Case Review 812 kb 09/13/2012
Y
705 Health Tracks - Appointment Slip 289 kb 01/28/2013
Y
706 Affidavit of Explanation Why Citizenship Cannot be Supplied 184 kb 08/17/2012
Y
707 Citizen Affidavit 290 kb 08/17/2012
Y
710 Health Tracks - Referral and Request for Information 48 kb 08/17/2012
Y
718 P Card Record 387 kb 01/03/2013
Y
719 TANF Request for Benefits 403 kb 08/17/2012
Y
734 P Card Transmittal Cover Sheet 176 kb 11/24/2009
Y
735 Diversion Assistance-Screening 192 kb 08/17/2012
Y
737 Diversion Assistance Action Plan 428 kb 11/29/2007
Y
743 Children's Hospice Waiver Application 310 kb 08/17/2012
Y
747 Appeal Form 227 kb 10/16/2007
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 Cancellation of Warrants or Checks 367 kb 09/25/2009
Y
788 Group Living Arrangement And Drug/Alcohol Treatment Center Report 324 kb 08/09/2010
Y
805 Request for an Exemption from the TANF Lifetime Limit 180 kb 08/17/2012
Y
816 Change Report for Adoption Assistance 270 kb
Y
817 Health Insurance Cost-Effectiveness Review 246 kb
Y
820 SPED Income and Assets 234 kb 08/27/2007
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 492 kb 08/17/2012
Y
832 Application to be Licensed/Early Childhood Services 578 kb 12/13/2012
Y
833 Patient Consent for a Telemedicine Encounter 97 kb 03/12/2008
N
841 Child Care Assistance Redetermination 953 kb 02/08/2013
Y
848 Providers's Request to Pay Parent Directly 192 kb 08/17/2012
Y
852 Sending State Expedited Home Study Request 446 kb 12/05/2011
Y
854 Title IV-E Adoption Subsidy Application 275 kb
Y
856 Adoption Subsidy Agreement Annual Review 266 kb
Y
869 Title 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 123 kb
Y
878 Crossroads Program Evaluation 474 kb 08/17/2012
Y
885 Statement of Case Worker 419 kb 10/13/2011
Y
889 Home Study Foster Care for Children and Youth 3187 kb 03/05/2014
Y
893 Step One/License Application to Provide Family Foster Care 837 kb 02/04/2014
Y
915 Adult Family Foster Care Home Affidavit of Standard Compliance-In Lieu of License 36 kb
N
925 Home & Community Based Care for the Elderly/Disabled Turnaround Document 244 kb 08/17/2012
Y
944 Request for Attendant Care Services 393 kb 03/03/2008
Y
958 Health Care Application for the Elderly and Disabled 1984 kb 01/07/2014
Y
961 Child Protection Report 98 kb
Y
963 TCM Assessment 462 kb 08/17/2012
Y
965 Interstate Compact on the Placement of Children Request-ICPC 100A 253 kb
Y
966 Interstate Compact on the Placement of Children Report on Child's Placement Status-ICPC 100B 255 kb
Y
970 Multi-Agency Authorization To Disclose Information 329 kb 04/10/2014
Y
980 Individual Request To Be A Qualitifed Service Provider/AFFC Provider 579 kb 11/01/2012
Y
1012 Monthly Rate Worksheet - Live In Care 733 kb 01/27/2014
Y
1013 Application to Provide Adult Family Foster Care 345 kb 09/24/2007
Y
1023 Foster Care Transportation Reimbursement Budget Sheet 324 kb 11/13/2012
Y
1031 Relicensing Study-Adult Family Foster Care 1456 kb 05/07/2013
Y
1032 Request for Law Enforcement 258 kb 01/04/2011
Y
1050 Paris Match (Duplicate Benefits) Out-of-State Inquiry 611 kb 01/13/2014
Y
1059 Authorization To Disclose Information 129 kb 08/17/2012
Y
1076 Grower's Statement 383 kb 08/09/2010
Y
1088 Client Financial Responsibility Supplemental Information 377 kb 02/12/2014
Y
1154 Medicaid Waiver Quality Review 515 kb 05/14/2012
Y
1168 Ownership Controlling Interest & Conviction Information 1294 kb 04/09/2014
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 Alcohol and Drug Abuse Patient Identifying Information 325 kb 05/17/2013
Y
1186 Notice to Insurer of Annuity of State's Right as A Preferred Remainder Beneficiary Due to Medicaid Benefits Provided 203 kb 05/28/2008
Y
1221 Intensive In-Home Family Services 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 and Alternative Resolution 227 kb 09/02/2010
Y
1251 Foster Parent Request for Formal Grievance Hearing 237 kb 09/02/2010
Y
1252 Notice of Formal Grievance Hearing 263 kb 09/02/2010
Y
1253 Results of Formal Grievance Hearing 229 kb 09/02/2010
Y
1265 ND Vulnerable Adult Protective Services/Data Collection 210 kb
Y
1266 ND Vulnerable Adult Protective Service Recommendations/Plans 96 kb
Y
1267 ND Vulnerable Adult Protective Services/Risk Assessment 606 kb
Y
1268 ND Vulnerable Adult Protective Services Screening Report 132 kb
Y
1288 CSSB Request for HCBS NF Determination 133 kb 02/22/2007
Y
1467 Individual Care Plan 611 kb 03/24/2014
Y
1474 Contractor State Fleet Vehicle Use Orientation 348 kb 05/21/2013
Y
1478 Notice of Invalid Authorization to Disclose Information 400 kb 01/28/2014
Y
1494 North Dakota Review Worksheet 1752 kb 06/18/2012
Y
1510 OAE/TYMP Screening 367 kb 05/07/2013
Y
1540 Income Averaging/Annualizing Worksheet 360 kb
Y
1593 Extended Services Employment Plan 431 kb 03/13/2012
Y
1594 Extended Services Verification of Available Funds 460 kb 03/13/2012
Y
1597 Explanation of Client Choice-Medicaid Waiver for the Aged and Disabled 235 kb
Y
1598 Medically Frail Questionnaire 822 kb 01/06/2014
Y
1607 Report of Suspected Vulnerable Adult Abuse, Neglect, or Exploitation 435 kb 07/18/2013
Y
1618 Application-Appendix A 665 kb 08/30/2013
Y
1647 HCBS Notice of Denial or Termination 194 kb 04/03/2007
Y
1681 Near Zero Income Sheet 172 kb
Y
1699 Authorization to Provide Services 831 kb 03/24/2014
Y
1703 Compliance Checklist/Adult Day Care Standards 70 kb
Y
1765 Request for Reimbursement/Non-State Employee 620 kb 04/22/2014
Y
1775 Authorization for Out-of-State Travel 475 kb 01/14/2014
Y
1781 Understanding of the Parties for Continued Foster Care Services 180 kb
Y
1784 Appeal Background Report 277 kb 08/09/2010
Y
1803 Subsidized Adoption Agreement 310 kb
Y
1810 Authorization to Provide Developmental Disability Services 307 kb 10/17/2012
Y
1811 Individual Care Plan-Developmental Disabilities 439 kb 10/17/2012
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 456 kb 12/04/2013
Y
1830 Application for Continued Guardianship Subsidy After Age 18 443 kb 07/12/2012
Y
1831 Guardianship Subsidy Agreement - Annual Review 183 kb
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
1865 Specialized Family Foster Care/Adoption Assistance Level of Care Evaluation 139 kb
Y
1906 Anticipated Self-Employment Worksheet 293 kb
Y
1906 Anticipated Self-Employment Worksheet (Printable) 216 kb
N
1909 Application for Health Coverage and Help Paying Costs 3215 kb 12/09/2013
Y
1910 Work Readiness Assessment Questionnaire 6164 kb 10/02/2013
Y
1920 Administrative Assessment or Referral 501 kb 04/30/2009
Y
1921 Aid to Blind/Remedial (Denial Notice) 316 kb 04/18/2012
Y
1940 TANF/SNAP Notice of Suspected Intentional Program Violation 568 kb 12/13/2013
Y
1941 Family Foster Home Annual Licensing Report 696 kb 04/09/2014
Y
1977 Request for Confidential Communication by Alternative Means or Alternative Location 416 kb 09/30/2013
Y
1978 Request to Transmit Electronic Protected Health Information (PHI) to Third Party 406 kb 09/30/2013
Y
1979 Request to Access Confidential Information 484 kb 09/30/2013
Y
1981 Request to Amend Records-Proteched Health Information (PHI) 452 kb 09/30/2013
Y
59529 DHS Employee Cultural Awareness Survey 997 kb 05/17/2011
Y