Forms

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Department of Human Services - Public Form(s)

SFNTitleSizeDateFillable
2 FFATA Certification 322 kb 11/06/2012
Y
15 Home Health Extended Home Health Request for Services Authorization 267 kb 09/03/2014
Y
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 10/31/2014
Y
43 National Provider Identifier (NPI) Registration 226 kb
Y
52 Spousal Assets 505 kb 08/17/2012
Y
53 Children's Hospice Service Plan 523 kb 12/29/2011
Y
55 Statement of Actual Costs - In-home Services 78 kb
N
56 Expanded SPED Program Data 192 kb 04/16/2010
Y
61 Public Health Tracks Comprehensive Orthodontic Screening 508 kb 01/25/2013
Y
62 Emergency Assistance Application 326 kb
Y
64 Request for Extra Time Individuals with Developmental Disabilities 210 kb 04/07/2010
Y
73 Partial Hospitalization - Pre-Authorization 605 kb 09/03/2014
Y
91 Revocation of Authorization to Disclose Information 340 kb 09/30/2013
Y
107 Social/Emotional Developmental/Well Being Screening Preliminary Questions 339 kb
Y
113 Postsecondary Education Information 336 kb 02/08/2013
Y
114 Nursing Facility Request for State Retro Leval of Care Review 257 kb 04/26/2010
Y
115 Family/Group Child Care Facility Fire Safety Checklist 448 kb 10/08/2012
Y
116 Quality Assurance Checklist 447 kb 10/16/2014
Y
123 Brand Name NSAID/COX2 Prior Authorization 193 kb
Y
124 Dispense as Written Prior Authorization 176 kb
Y
125 ARB Authorization 172 kb
Y
126 ACE Inhibitor Prior Authorization 177 kb
Y
129 Alternative to Abortion Services Payment Voucher 602 kb 12/28/2010
Y
135 ND Family Caregiver Support Program Provider Service Log-Individual 499 kb 12/10/2014
Y
143 Civil Rights Complaint 905 kb 10/14/2013
N
152 Child Support Verification 108 kb
Y
161 Direct Deposit Enrollment and Authorization 269 kb 08/18/2010
Y
162 Request for Hearing 366 kb 08/17/2012
Y
167 Determination of Availability of Employer-Based Health Insurance 276 kb 08/17/2012
Y
168 North Dakota Medicaid Provider Appeal 359 kb 02/19/2014
Y
171 Foster Program Subsidized Employment Agreement 247 kb 02/03/2010
Y
200 Asset Assessment 930 kb 08/25/2014
Y
205 Group and Residential Child Care Facilities Annual Review and Statement of Compliance 1349 kb 02/07/2013
Y
209 Childcare Facility Fire Drill and Smoke Detector Testing Record 225 kb
Y
212 Rural Differential Closure 391 kb 12/09/2014
Y
215 Child Care Center and Preschool Fire Safety Checklist 561 kb 10/08/2012
Y
223 Fire Inspection Certification 214 kb
Y
224 Private Duty Nursing Prior Authorization 422 kb 09/03/2014
Y
228 Workers with Disabilities Report-Part II 482 kb 08/17/2012
Y
234 Insurance Coverage Statement 197 kb
Y
235 Criminal Offense Conviction Statement 197 kb
Y
236 Financial Disclosure Statement 161 kb
Y
247 MDS Appeal Request 386 kb 09/19/2014
Y
252 Chafee Education and Training Voucher Program (ETV)- 901 kb 08/22/2013
Y
255 Chafee Foster Care Independence Program Unaccompanied Refugee Minor Program Request for Financial Assistance 326 kb 12/28/2010
Y
269 Monthly Data and Payment Report 508 kb 01/02/2013
Y
270 Request for Replacement Due to Loss of Food Purchased with Snap Benefits 341 kb 08/17/2012
Y
292 Request for Prior Authorization for Vision Services 538 kb 09/03/2014
Y
308 Medicaid and Basic Care Assistance Programs Provider Agreement 172 kb
Y
312 Correction Order Notification and Child Care Provider Confirmation 192 kb 06/12/2013
Y
323 Jobs Status Change 158 kb 11/08/2012
Y
327 Family Foster Care Home Claim of Property Damage 176 kb 10/16/2007
Y
328 Family Foster Care Home Property Damage Verification of Claim 495 kb 06/20/2013
Y
343 Child Care Documentation Record For TB Testing, CPR, First Aid and Training 573 kb 12/17/2013
Y
353 Affidavit for Best Registrants 320 kb 08/17/2012
Y
369 Application for Family Therapy-Intensive 786 kb 10/22/2010
Y
373 Authorization for Background Check/Military/Reservation 319 kb 12/02/2008
Y
377 Background Check Address Disclosure/Release of Information 478 kb 08/05/2011
Y
383 Serious Accident or Injury/Illness/Death Report 592 kb 11/05/2012
Y
385 Affidavit for Work Registrants 318 kb 08/17/2012
Y
387 ICPC Supervision Report 248 kb 02/26/2009
Y
393 Children with Medically Fragile Needs-Clinical Criteria 596 kb 04/09/2008
Y
394 Children with Medically Fragile Needs Application 430 kb 12/09/2014
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
423 Kinship Placement 134 kb 06/12/2014
Y
424 Kinship Care Agreement 124 kb 06/12/2014
Y
427 Nursing Home Census Data Report 93 kb
Y
429 Memorandum Of Agreement To Establish Protective Payments 205 kb 08/17/2012
Y
433 Child Abuse and Neglect Background Inquiry 477 kb 12/16/2014
Y
438 Incident Report 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/Incapacity 485 kb 09/19/2012
Y
452 Application for a License to Operate an Assisted Living Facility 647 kb 02/07/2013
Y
462 Request for Appeal of the CA/N Assessment Decision 311 kb 03/26/2013
Y
465 Request for Grievance Meeting to Review the Conduct of CA/N Assessment 54 kb 01/08/2010
Y
466 Background Check Address Disclosure 326 kb 01/19/2010
Y
467 Personal Authorization for Criminal Record Inquiry-Foster Care 433 kb 01/13/2012
Y
471 Vendor Payment (TANF) Authorization and Request For Payment For Goods and Services 449 kb 08/17/2012
Y
481 Service Limits Service Authorization Request 474 kb 09/03/2014
Y
492 ND Family Caregiver Support Program Provider Service Log-Agency 622 kb 12/10/2014
Y
507 Step One: Voluntary Treatment Program Application 676 kb
Y
508 Authorization for Child Abuse and Neglect Background Check 400 kb 11/28/2014
Y
509 Out-of-State Enrollment Clarification 93 kb 08/19/2013
Y
511 Medical Procedure/Device Authorization Request 442 kb 09/03/2014
Y
517 Child Care Evacuation Disaster Plan 364 kb 03/10/2010
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 Certifcate of Medical Necessity-Infant Apnea Monitor 265 kb 07/31/2007
Y
529 Application: Heating Assistance Program 1694 kb 10/23/2014
Y
560 Assignment of Benefits 197 kb 08/17/2012
Y
566 Medicaid Questionnaire and Assignment 501 kb 04/04/2013
Y
594 Application for Recertification: Mental Health Technician 528 kb 10/07/2014
Y
596 Application for Certification: Mental Health Technician 498 kb 10/07/2014
Y
598 Child Care Assistance Application 1944 kb 08/07/2013
Y
606 Medicaid Out of State Services Certification 320 kb 02/27/2012
Y
614 Physician Certification for Sterilization and Recipient Acknowledgement of Sterility 261 kb 10/20/2008
N
615 Medicaid Program Provider Agreement 410 kb 11/03/2014
Y
616 Child Care Billing Report 946 kb 08/17/2012
Y
620 Non-Emergent Medical Transportation 1677 kb 07/15/2014
Y
630 Foster Care Placement Notification & Preliminary Eligibility Determination 523 kb 04/29/2013
Y
634 Claim Form - Drug/Pharmacy 140 kb
Y
639 Provider Request for an Adjustment 100 kb
Y
640 Pharmacy Request for an Adjustment 89 kb
Y
641 Title IV-E Title XIX Application-Foster Care 635 kb 08/17/2012
Y
659 Respite Home Evaluation 295 kb
Y
661 Electronic Funds Transfer (EFT) 272 kb 06/14/2010
Y
670 Child Care Assistance Change Report 744 kb 08/01/2013
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
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
708 Primay Care Case Management (PCCM) Program Referral 377 kb 01/25/2013
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 Wheelchairs 240 kb
Y
722 Certificate of Medical Necessity - Osteogenesis Stimulators 239 kb
Y
724 Certificate of Medical Necessity - Seat Lift Mechanism 217 kb
Y
725 Accounting of Disclosure Request 381 kb 09/30/2013
Y
726 Certificate of Medical Necessity - Parenteral Nutrition 196 kb
Y
727 Certificate of Medical Necessity - Section C Continuation Form 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 192 kb 08/17/2012
Y
743 Children's Hospice Waiver Application 310 kb 08/17/2012
Y
750 Documentation of Competency 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 Prior Authorization for Out-of-State Services 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 and/or Enteral Nutrition 396 kb 04/17/2012
Y
785 Certificate of Medical Necessity-Hospital Beds 237 kb
Y
789 Certificate of Medical Necessity-TENS 200 kb
Y
800 Fire Safety Self Declaration 545 kb 03/12/2013
Y
805 Request for an Exemption from the TANF Lifetime Limit 180 kb 08/17/2012
Y
812 Child Intake Record 416 kb 04/13/2010
Y
823 Family Evacuation Disaster Plan 361 kb 09/11/2008
Y
824 Universal Application 2544 kb 07/06/2010
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
838 Personal Authorization for Criminal History Background Check Inquiry 824 kb 03/24/2014
Y
841 Child Care Assistance Redetermination 953 kb 02/08/2013
Y
845 Child Information Sheet 507 kb 12/17/2013
Y
846 Release of Information-Child Care Facility 174 kb
Y
847 Parent's Statement On Health Of Child 490 kb 07/26/2011
Y
848 Providers's Request to Pay Parent Directly 192 kb 08/17/2012
Y
850 Proton Pump Inhibitor Prior Authorization 195 kb
Y
851 Anti-Histamine Prior Authorization 179 kb
Y
865 Application for Self-Declaration Document 569 kb 07/16/2014
Y
875 False Claims Education Certification 236 kb 04/27/2007
Y
878 Crossroads Program Evaluation 642 kb 10/31/2014
Y
879 Crossroads Evaluation (School) 520 kb 10/31/2014
Y
886 Application for Child Placing Agency License-Foster Care 1208 kb 02/20/2013
Y
898 Application for License Group/Residential Child Care Facility 2486 kb 10/22/2013
Y
904 Agreement to Furnish Specialized Family Foster Care Services 233 kb 08/15/2008
Y
905 Technology/Procedure Assessment 284 kb 03/30/2010
Y
925 Home & Community Based Care for the Elderly/Disabled Turnaround Document 244 kb 08/17/2012
Y
930 Birthparent Background Information 1.1 Mb
Y
933 Request For Privacy Officer Review 361 kb 09/30/2013
Y
934 Request For Privacy Conference 361 kb 09/30/2013
Y
936 Acknowledgement of Receipt of the Notice of Privacy Practices 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 330 kb
Y
942 Search/Disclosure Notice of Rights 184 kb
Y
945 Certification to the ND Dept. of Human Services 201 kb
Y
946 Affidavit 167 kb
Y
947 Notice of Intent 189 kb
Y
948 Notice of Intent/Guarantee of REsponsibility 222 kb
Y
958 Health Care Application for the Elderly and Disabled 2011 kb 12/04/2014
Y
960 Report of Suspected Child Abuse or Neglect 48 kb 08/16/2012
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 290 kb 06/12/2014
Y
969 Orientation Certification 279 kb 01/19/2011
Y
970 Multi-Agency Authorization To Disclose Information 329 kb 04/10/2014
Y
972 Declaration of Good Health 296 kb 09/27/2010
Y
980 Individual Request To Be A Qualitifed Service Provider/AFFC Provider 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 127 kb
Y
1018 New Hire Reporing Information 702 kb 10/01/2013
Y
1033 Travel Authorization 430 kb 05/29/2014
Y
1041 Child Care Death Report 518 kb 06/12/2012
Y
1047 Application for Service 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 410 kb
Y
1084 Notice of the ND Department of Human Services Determination of Special Needs 203 kb
Y
1115 Service Authorization Request 605 kb 09/04/2014
Y
1125 Extended Services Monthly Progress Summary 858 kb 01/10/2012
Y
1130 Hour by Hour Enrollment and Staffing Schedule for Group Child Care 1287 kb 09/21/2011
Y
1146 Non-Profit Clinic Dental Access Project Application 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 & Conviction Information 1294 kb 04/09/2014
Y
1169 Pharmacy Agreement/Medical Assistance Program 369 kb 01/25/2013
Y
1177 Request for Guardianship Establishment Funds 889 kb 02/28/2014
Y
1224 Medical/Child Support Questionnaire 248 kb
Y
1257 Compliance Check List/School Age Child Care Center 2643 kb 09/15/2014
Y
1269 Child Care Concern Form 601 kb 12/17/2013
Y
1276 Early Childhood Services Review 1629 kb 07/16/2014
Y
1296 Contract to Provide Primary Care Case Management Services 682 kb 05/08/2014
Y
1384 HCBS Electronic Web-File transfer Registration 303 kb 10/29/2012
Y
1422 Compliance Check List/Family Child Care Homes 2690 kb 12/02/2014
Y
1423 Compliance Checklist/Child Care Center 3784 kb 09/11/2014
Y
1424 Compliance Check List/Preschool Educational Facilities 2851 kb 09/15/2014
Y
1425 Compliance checklist/Group Child Care 3805 kb 12/02/2014
Y
1426 Child Care Record 271 kb 04/21/2009
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 495 kb 11/13/2014
Y
1547 License Application/Day Services 474 kb 11/10/2014
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 Group Home Facilities 346 kb
Y
1556 Plan of Correction 159 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
1595 Self-Declaration Provider Review 485 kb 12/17/2013
Y
1598 Medically Frail Questionnaire 822 kb 01/06/2014
Y
1601 Group Provider Enrollment Application 2900 kb 04/24/2013
Y
1602 Individual Provider Enrollment Application 1800 kb 04/04/2013
Y
1603 Individual Request to be a Qualified Service Provider 1692 kb 12/08/2014
Y
1604 Request to be a Qualified Service Provider for Family Home Care 1353 kb 07/22/2013
Y
1605 Individual Request to be a Qualified Service Provider/AFFC Provider 1617 kb 09/04/2014
Y
1606 Agency Request to be a Qualified Service Provider 1648 kb 06/13/2013
Y
1607 Report of Suspected Vulnerable Adult Abuse, Neglect, or Exploitation 526 kb 07/16/2014
Y
1618 Application-Appendix A 665 kb 08/30/2013
Y
1694 Search and Copying Services Records Requests 162 kb
Y
1763 Request for Reimbursement-Direct Service 680 kb 04/22/2014
Y
1765 Request for Reimbursement/Non-State Employee 620 kb 04/22/2014
Y
1804 County Jail Medical Claims Processing-Member Enrollment 399 kb 06/21/2013
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
1853 Request for Rehabilitative Services for Medicaid Eligible Enrollees 351 kb 11/30/2012
Y
1907 Inclusion Support Grant Application 365 kb 11/05/2013
Y
1909 Application for Health Coverage and Help Paying Costs 4945 kb 12/05/2014
Y
1910 Work Readiness Assessment Questionnaire 6164 kb 10/02/2013
Y
1967 Opt-Out of Making Income Withholding Payments Electronically 275 kb 04/22/2014
Y
1968 Request for Waiver for Good Cause-Special Difficulty Associated with Making Income Withholding Payments Electronically 310 kb 11/13/2014
Y
1969 Request for Waiver for Good Cause-Special Difficulty Associated with Reporting New Hires Electronically 309 kb 04/22/2014
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
1980 Request to Restrict the Use and Disclosure of Protected Health Information (PHI) 509 kb 09/30/2013
Y
1981 Request to Amend Records-Proteched Health Information (PHI) 452 kb 09/30/2013
Y
1992 Release of Information-Search/Disclosure 226 kb
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 (3-7) 1204 kb 06/25/2014
Y
60602 Registration Intake Sheet 1519 kb 06/27/2014
Y
60603 General Incident Report 650 kb 06/25/2014
Y
60604 Data Collection for Incident: Injury 998 kb 06/25/2014
Y
60605 Data Collection for Incident: Medication Error 665 kb 06/25/2014
Y
60606 Data Collection for Incident: Retraint Related to Behavior 475 kb 06/25/2014
Y
60607 Data Collection for Incident: Restraint Other 504 kb 06/25/2014
Y
60608 Data Collection for Incident: Deatj 570 kb 06/25/2014
Y
60609 Data Collection for Incident: Other 592 kb 06/25/2014
Y
60610 Witness Entry: Restraint 523 kb 06/25/2014
Y
60611 Application for Autism Voucher 1771 kb 09/11/2014
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: Respite Care 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 Behavior Design and Monitoring Report 450 kb 06/25/2014
Y
60618 Applicaition for North Dakota Autism Waiver 803 kb 09/11/2014
Y
60619 Waiver Application Case Action Report 446 kb 06/25/2014
Y
60620 MMIS Authorizations-Autism Waiver 484 kb 11/14/2014
Y
60677 Assistive Technology/Voucher Purchase Request 439 kb 11/14/2014
Y
60680 Eligibility and Level of Support Recommendations Vineland Adaptive Behavior Scales (VABS) 535 kb 07/01/2014
Y