Forms

  • For best results, use the current version of Adobe Acrobat Reader.
  • Forms that are marked with a Y in the Fill column can be completed on-line through Adobe Acrobat Reader.
  • Users with Adobe 6.0 and above will need to change a setting before completing the forms so that the tabbing order works correctly. Open Adobe Acrobat, go to the tab on top labeled Edit, go to Preferences, and Accessibility. Make sure the box Use document structure for tab order when no explicit tab order is specified is not checked.
  • Select the appropriate form and click in the first text box to be completed.
  • Enter the required information and tab over or click on the next text box to continue completing the form.
  • Dates must be entered in the following format: mm/dd/yyyy.
  • When printing a form from Adobe Acrobat, the Page Scaling needs to be set to None. This can be found under File, Print, Page Handling Section. There will be a section called Page Scaling with drop down options. Please select None from those options. If any of the other options are selected, additional white space will be added to the margins of the form and the form will shrink.

Department of Human Services - Public Form(s)

SFNTitleSizeDateFillable
2 FFATA Certification 322 kb 11/06/2012
Y
15 Home Health Request for Prior Authorization 330 kb 03/21/2012
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 473 kb 02/08/2013
Y
29 Crossroads Program Application 468 kb 08/17/2012
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
66 Public Health Tracks Interactive Orthodontic Screening 222 kb 08/17/2012
Y
73 Partial Hospitalization - Pre-Authorization 576 kb 01/18/2013
Y
91 Revocation of Authorization to Disclose Information 95 kb 08/17/2012
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
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 468 kb 07/27/2011
Y
143 Civil Rights Complaint 396 kb 06/11/2012
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 159 kb
Y
171 Foster Program Subsidized Employment Agreement 247 kb 02/03/2010
Y
200 Asset Assessment 272 kb 08/17/2012
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
215 Child Care Center and Preschool Fire Safety Checklist 561 kb 10/08/2012
Y
223 Fire Inspection Certification 214 kb
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
252 Chafee Education and Training Voucher Program (ETV)- 756 kb 12/28/2010
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 526 kb 04/29/2013
Y
308 Medicaid and Basic Care Assistance Programs Provider Agreement 172 kb
Y
312 Correction Order Notification and Child Care Provider Confirmation 139 kb 07/21/2010
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 267 kb 08/09/2010
Y
343 Child Care Documentation Record For TB Testing, CPR, First Aid and Training 621 kb 12/15/2011
Y
351 Case Activity Log 18 kb
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 246 kb 08/17/2012
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 111 kb
Y
424 Kinship Care Agreement 110 kb
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 283 kb 08/17/2012
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
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 Prior Authorization Request 391 kb 11/19/2012
Y
492 ND Family Caregiver Support Program Provider Service Log-Agency 590 kb 10/10/2011
Y
502 Application for Health Care Coverage for Children, Families, and Pregnant Women 467 kb 08/17/2012
Y
507 Step One: Voluntary Treatment Program Application 676 kb
Y
508 Authorization for Child Abuse and Negliect Background Check 355 kb 04/10/2012
Y
511 Medical Procedure/Device Prior Authorization Request 309 kb 11/24/2010
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 1646 kb 07/13/2011
Y
541 Request to be a Qualified Service Provider for Family Home Care 574 kb 08/17/2012
Y
560 Assignment of Benefits 197 kb 08/17/2012
Y
566 Medicaid Questionnaire and Assignment 501 kb 04/04/2013
Y
598 Child Care Assistance Application 1306 kb 02/08/2013
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 394 kb 02/26/2013
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
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 702 kb 08/17/2012
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 50 kb
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
740 Initial/Strength/Full Assessment 395 kb
Y
743 Children's Hospice Waiver Application 310 kb 08/17/2012
Y
748 Individual Request to be a Qualified Service Provider 658 kb 08/17/2012
Y
749 Agency Request to be a Qualified Service Provider 596 kb 08/17/2012
Y
750 Documentation of Competency 948 kb 07/02/2012
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 572 kb 11/04/2010
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 814 kb 03/26/2012
Y
841 Child Care Assistance Redetermination 953 kb 02/08/2013
Y
845 Child Information Sheet 522 kb 12/27/2010
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 517 kb 03/15/2011
Y
875 False Claims Education Certification 236 kb 04/27/2007
Y
878 Crossroads Program Evaluation 474 kb 08/17/2012
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 1344 kb 02/07/2013
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 95 kb
Y
934 Request For Privacy Conference 110 kb
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 1237 kb 10/01/2012
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 255 kb
Y
969 Orientation Certification 279 kb 01/19/2011
Y
970 Multi-Agency Authorization To Disclose Information 433 kb 08/17/2012
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 314 kb 01/31/2012
Y
987 Affidavit of Standard Compliance and Child Care Provider Certification 349 kb 02/22/2010
Y
989 Sterilization Consent 127 kb
Y
1018 New Hire Reporing Information 669 kb 12/19/2011
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 Prior Authorization Request 455 kb 02/19/2013
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 303 kb 09/18/2012
Y
1150 Early Childhood Services Application for Waiver of Ratio 358 kb 08/31/2012
Y
1168 Ownership Controlling Interest & Conviction Information 497 kb 03/19/2013
Y
1169 Pharmacy Agreement/Medical Assistance Program 369 kb 01/25/2013
Y
1177 Request for Guardianship Establishment Funds 852 kb 03/12/2012
Y
1224 Medical/Child Support Questionnaire 248 kb
Y
1257 Compliance Check List/School Age Child Care Center 2641 kb 12/12/2011
Y
1269 Child Care Concern Form 593 kb 11/05/2012
Y
1276 Early Childhood Services Review 1091 kb 03/19/2013
Y
1384 HCBS Electronic Web-File transfer Registration 303 kb 10/29/2012
Y
1422 Compliance Check List/Family Child Care Homes 2537 kb 05/17/2011
Y
1423 Compliance Checklist/Child Care Center 3799 kb 06/28/2011
Y
1424 Compliance Check List/Preschool Educational Facilities 2870 kb 07/13/2011
Y
1425 Compliance checklist/Group Child Care 2122 kb 08/06/2012
Y
1426 Child Care Record 271 kb 04/21/2009
Y
1505 Additional Service Location: Group Provider 1350 kb 04/03/2013
Y
1508 Primary Care Enhanced Payment Increase Self-Attestation 665 kb 05/22/2013
Y
1509 Additional Service Location: Individual Provider 1290 kb 04/04/2013
Y
1544 Policies and Procedures Checklist 190 kb
Y
1545 Sanitation Inspection Certification 212 kb
Y
1546 License Application/Residential Services 211 kb
Y
1547 License Application/Day Services 210 kb
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
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 1937 kb 04/24/2013
Y
1604 Request to be a Qualified Service Provider for Family Home Care 1753 kb 04/24/2013
Y
1605 Individual Request to be a Qualified Service Provider/AFFC Provider 2058 kb 04/24/2013
Y
1606 Agency Request to be a Qualified Service Provider 1387 kb 04/24/2013
Y
1694 Search and Copying Services Records Requests 162 kb
Y
1763 Request for Reimbursement-Direct Service 288 kb
Y
1765 Request for Reimbursement/Non-State Employee 231 kb
Y
1804 County Jail Medical Claims Processing-Member Enrollment 332 kb 04/02/2013
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
1967 Opt-Out of Making Income Withholding Payments Electronically 232 kb 10/19/2012
Y
1968 Request for Waiver for Good Cause-Special Difficulty Associated with Making Income Withholding Payments Electronically 253 kb 10/31/2012
Y
1969 Request for Waiver for Good Cause-Special Difficulty Associated with Reporting New Hires Electronically 253 kb 10/19/2012
Y
1992 Release of Information-Search/Disclosure 226 kb
Y
59529 DHS Employee Cultural Awareness Survey 997 kb 05/17/2011
Y