SFN | Title | Size | Date | Fillable |
2
|
FFATA CERTIFICATION
|
900 kb
|
03/30/2022
|
Y
|
9
|
MEDICAID REHAB SERVICES PROVIDER ENROLLMENT ATTESTATION
|
961 kb
|
06/02/2021
|
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
|
848 kb
|
01/04/2022
|
Y
|
49
|
CHILD CARE ASSISTANCE PROGRAM DIRECT DEPOSIT BANKING INFO
|
834 kb
|
01/27/2022
|
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
|
372 kb
|
01/10/2022
|
Y
|
62
|
EMERGENCY ASSISTANCE APPLICATION
|
326 kb
|
|
Y
|
64
|
RQUEST FOR EXTRA TIME INDIVIDUALS WITH DEVELOPMENTAL DISABIL
|
354 kb
|
05/04/2021
|
Y
|
73
|
PARTIAL HOSPITALIZATION PROGRAM (PHP) SERVICE AUTHORIZATION
|
439 kb
|
10/26/2020
|
Y
|
74
|
CHILD SUPPORT INFORMATION
|
1057 kb
|
05/24/2022
|
Y
|
79
|
SUBSTANCE USE DISORDER SERVICE AUTHORIZATION REQUEST
|
474 kb
|
06/04/2021
|
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
|
116
|
QUALITY ASSURANCE CHECKLIST-EARLY CHILDHOOD SERVICES (ECS)
|
1292 kb
|
05/25/2021
|
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
|
498 kb
|
10/06/2021
|
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
|
604 kb
|
05/20/2022
|
Y
|
185
|
AWARE ND APPLICATION SUPPLEMENT
|
1370 kb
|
05/20/2022
|
Y
|
200
|
ASSET ASSESSMENT
|
1096 kb
|
09/08/2017
|
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
|
243
|
ND DRIVERS LICENSE VERIFICATION FOR STATE FLEET OPERATORS
|
919 kb
|
02/01/2022
|
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
|
279
|
PROVIDER NOTICE OF COMPLETED CORRECTION ORDER
|
1285 kb
|
04/15/2021
|
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
|
299
|
INSTITUTIONAL CHILD PROTECTION SERVICES ASSESSMENT
|
2114 kb
|
08/06/2021
|
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 PROVIDER ACKNOWLEDGEMENT
|
1289 kb
|
05/03/2021
|
Y
|
323
|
JOBS STATUS OF CHANGE
|
893 kb
|
07/07/2021
|
Y
|
327
|
FAMILY FOSTER CARE HOME CLAIM OF PROPERTY DAMAGE
|
977 kb
|
01/13/2022
|
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
|
351
|
COMPANIONSHIP RURAL DIFFERENTIAL RATE AUTHORIZATION
|
906 kb
|
03/22/2022
|
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
|
374
|
APPLICATION CONTRACT FOR CHILD SUPPORT ENFORCE-CUSTD PARENT
|
918 kb
|
09/28/2018
|
Y
|
375
|
AUTHOR TO TRANSFER BACKGROUND CHECK RESULTS-EARLY CHILDHOOD
|
913 kb
|
05/13/2022
|
Y
|
379
|
CORRECTION ORDER
|
1289 kb
|
02/02/2021
|
Y
|
380
|
UNLICENSED CHILD CARE PROVIDER AFFIDAVIT
|
900 kb
|
05/09/2022
|
Y
|
382
|
CHILD CARE LICENSING LETTER
|
895 kb
|
05/09/2022
|
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
|
390
|
CORRECTION ORDER REINSPECTION
|
1288 kb
|
04/12/2021
|
Y
|
393
|
MFCU CLINICAL CRITERIA
|
596 kb
|
04/09/2008
|
Y
|
394
|
CHILDREN WITH MEDICALLY FRAGILE NEEDS APPLICATION
|
424 kb
|
03/09/2018
|
Y
|
404
|
MEDICAID WAIVER PERSON CENTERED PLAN OF CARE
|
676 kb
|
10/29/2021
|
Y
|
405
|
APPLICATION FOR ASSISTANCE
|
4471 kb
|
05/09/2022
|
Y
|
408
|
KINSHIP NAVIGATION SERVICES APPLICATION
|
1117 kb
|
12/10/2021
|
Y
|
410
|
PRELIMINARY AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICE
|
928 kb
|
06/23/2021
|
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
|
938 kb
|
12/10/2021
|
Y
|
438
|
INCIDENT REPORT
|
1294 kb
|
12/15/2020
|
Y
|
443
|
NOTICE OF RIGHT TO CLAIM GOOD CAUSE
|
111 kb
|
08/21/2012
|
Y
|
446
|
REQUEST TO CLAIM GOOD CAUSE
|
88 kb
|
08/17/2012
|
Y
|
447
|
EXCEPTION FOR SUBMITTING ELECTRONIC CLAIMS
|
301 kb
|
04/06/2022
|
Y
|
451
|
ELIGIBILITY REPORT ON DISABILITY INCAPAS
|
456 kb
|
10/18/2021
|
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
|
923 kb
|
02/15/2022
|
Y
|
474
|
HCBS CASE CLOSURE/PROVIDER TERMINATION
|
350 kb
|
03/10/2022
|
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
|
489 kb
|
09/07/2021
|
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
|
507
|
STEP ONE VOLUNTARY TREATMENT PROGRAM APPLICATION
|
709 kb
|
06/05/2015
|
Y
|
509
|
OUT OF STATE/OUT OF NETWORK ENROLLMENT CLARIFICATION
|
148 kb
|
06/02/2021
|
Y
|
511
|
MEDICAL PROCEDURE/DEVICE SERVICE AUTHORIZATION REQUEST
|
506 kb
|
06/23/2020
|
Y
|
517
|
CHILD CARE EVACUATION DISASTER PLAN
|
1291 kb
|
11/15/2021
|
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
|
1135 kb
|
08/11/2021
|
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
|
559
|
LIFESPAN RESPITE CARE GRANT EMERG RESPITE PROVIDER AGREEMENT
|
950 kb
|
09/23/2021
|
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
|
311 kb
|
07/13/2021
|
Y
|
577
|
NURSE EDUCATOR NURSING PLAN OF CARE
|
350 kb
|
07/13/2021
|
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
|
SKILLED CARE REFERRAL FOR LONG-TERM SERVICES AND SUPPORTS
|
895 kb
|
09/15/2021
|
Y
|
586
|
APPLICATION FOR MIP INSTRUCTION CERTIFICATION/RECERTIF
|
947 kb
|
03/11/2022
|
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
|
09/08/2021
|
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
|
599
|
PRTF LICENSURE/REQUEST FOR CHANGE IN BED CAPACITY APPLICATIO
|
507 kb
|
09/23/2021
|
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
|
372 kb
|
01/26/2022
|
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
|
917 kb
|
12/27/2021
|
Y
|
626
|
DETERMINE IF A CONTRACT REQUIRES BBA AND A QSO AGREEMENT
|
1247 kb
|
06/10/2020
|
Y
|
630
|
FOSTER CARE PLACEMENT NOTIFICATION
|
982 kb
|
01/03/2022
|
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
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TITLE IV-E TITLE XIX APPLICATION - FOSTER CARE
|
2318 kb
|
08/12/2019
|
Y
|
643
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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
|
912 kb
|
01/07/2022
|
Y
|
650
|
ND PEER SUPPORT SPECIALIST RECERTIFICATION APPLICATION
|
919 kb
|
03/01/2022
|
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
|
06/02/2021
|
Y
|
662
|
PERSONAL CARE SERVICES PLAN OF CARE & AUTHORIZATION IN A LIC
|
640 kb
|
05/10/2022
|
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
|
406 kb
|
10/29/2021
|
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
|
1360 kb
|
12/14/2021
|
Y
|
740
|
COMPANIONSHIP BILLING WORKSHEET
|
1290 kb
|
10/28/2021
|
Y
|
741
|
1915(I) ELIGIBILITY APPLICATION
|
1615 kb
|
01/25/2022
|
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
|
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
|
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
|
1552 kb
|
06/16/2021
|
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
|
1097 kb
|
07/22/2021
|
Y
|
826
|
QUALIFIED RESDIENTIAL TRMT PROG (QRTP) CONTINUED STAY REVIEW
|
1027 kb
|
07/22/2021
|
Y
|
828
|
MEDICAL SERVICES PROGRAM REFUND/CREDIT REPORT
|
979 kb
|
04/08/2020
|
Y
|
829
|
PERSONAL AUTHORIZATION FOR CRIMINAL HISTORY RECORD INFO
|
961 kb
|
08/12/2021
|
Y
|
830
|
REQUEST FOR CLIENT SPECIFIC ENDORSEMENT
|
529 kb
|
04/17/2019
|
Y
|
832
|
EARLY CHILDHOOD SERVICES LICENSE APPLICATION
|
912 kb
|
06/14/2021
|
Y
|
833
|
PATIENT CONSENT FOR TELEMEDICINE ENCOUNTER
|
336 kb
|
12/20/2021
|
Y
|
834
|
APPLICATION FOR IN-HOME PROVIDER
|
1290 kb
|
04/20/2021
|
Y
|
836
|
FINGERPRINT IDENTITY VERIFICATION
|
905 kb
|
12/29/2020
|
Y
|
838
|
ANNUAL LICENSING APPLICATION-MATERNITY HOME
|
938 kb
|
03/03/2022
|
Y
|
839
|
FOSTER CARE OVERPAYMENT NOTIFICATION
|
932 kb
|
04/01/2021
|
Y
|
844
|
RELATIVE WAIVER FAMILY FOSTER HOMES
|
935 kb
|
09/17/2019
|
Y
|
845
|
CHILD INFORMATION SHEET
|
498 kb
|
05/11/2022
|
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
|
974 kb
|
03/30/2022
|
Y
|
851
|
LICENSING CHECKLIST FAMILY FOSTER HOMES
|
975 kb
|
04/26/2022
|
Y
|
855
|
TITLE IV-E ADOPTION SUBSIDY ELIGIBILITY DETERMINATION
|
263 kb
|
03/03/2021
|
Y
|
856
|
ADOPTION SUBSIDY AGREEMENT - REVIEW
|
945 kb
|
05/19/2022
|
Y
|
859
|
SUBSTANCE ABUSE DISORDER VOUCHER PROGRAM APPLICATION
|
898 kb
|
06/09/2021
|
Y
|
863
|
LICENSING CHANGE CHECKLIST-FAMILY FOSTER HOMES
|
985 kb
|
05/24/2022
|
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
|
1823 kb
|
05/03/2021
|
Y
|
886
|
APPLICATION FOR CHILD PLACING AGENCY LICENSE
|
990 kb
|
03/02/2022
|
Y
|
887
|
APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL)
|
1265 kb
|
09/16/2019
|
Y
|
888
|
PERSONAL AUTHORIZATION CRIM HISTORY INQ-CHILD ADVOCACY CTRS
|
972 kb
|
08/03/2021
|
Y
|
889
|
INITIAL HOME STUDY FOSTER CARE FOR CHILDREN
|
1149 kb
|
03/28/2022
|
Y
|
890
|
AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO
|
1478 kb
|
03/02/2022
|
Y
|
892
|
REFERRAL FOR LONG-TERM CARE SERVICES & SUPPORTS COUNSELING
|
986 kb
|
05/04/2022
|
Y
|
893
|
APPLICATION TO PROVIDE FAMILY FOSTER CARE FOR CHILDREN
|
893 kb
|
04/26/2022
|
Y
|
895
|
ADMISSION EXCEPTION REQUEST QRTP
|
939 kb
|
04/04/2022
|
Y
|
896
|
DISCHARGE EXCEPTION REQUEST QRTP
|
921 kb
|
04/04/2022
|
Y
|
898
|
ANNUAL LICENSING APPLICATION QRTP
|
2292 kb
|
09/17/2019
|
Y
|
902
|
FOSTER CARE LICENSING REFERENCE CHECK
|
777 kb
|
05/24/2022
|
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
|
926
|
MFP-EMERGENCY BACKUP PLAN
|
916 kb
|
11/17/2021
|
Y
|
928
|
AGREEMENT TO FURNISH SHELTER CARE
|
939 kb
|
05/11/2022
|
Y
|
929
|
RESPITE REQUEST AND PROVIDER AGREEMENT
|
988 kb
|
04/26/2022
|
Y
|
930
|
BACKGROUND INFORMATION FOR ADOPTION SERVICES
|
1.1 Mb
|
|
Y
|
931
|
SHELTER CARE PLACEMENT CLAIM
|
956 kb
|
05/17/2022
|
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
|
958
|
HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED
|
2254 kb
|
12/03/2021
|
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
|
335 kb
|
07/14/2021
|
Y
|
969
|
ORIENTATION CERTIFICATION
|
905 kb
|
07/28/2021
|
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
|
973
|
EXTENDED PERSONAL CARE SERVICE PROVIDER PROCEDURE & TRAINING
|
336 kb
|
04/15/2019
|
Y
|
974
|
PHYSCIAL EXAM VERIFICATION FAMILY FOSTER HOME
|
917 kb
|
03/16/2022
|
Y
|
985
|
APPLICATION FOR ELIGIBILITY DETERMINATION
|
1089 kb
|
09/14/2021
|
Y
|
986
|
COMMUNITY CONNECT PROGRAM PROVIDER APPLICATION
|
1557 kb
|
06/28/2021
|
Y
|
992
|
QUALITY ASSURANCE (QA) CASE REVIEW ADOPTION CASE NARRATIVE
|
1711 kb
|
05/02/2022
|
Y
|
993
|
QA CASE REVIEW CHILD PROTECTIVE SERVICES CASE NARRATIVE
|
1715 kb
|
05/03/2022
|
Y
|
995
|
QA CASE REVIEW FOSTER CARE CASE NARRATIVE
|
1303 kb
|
10/05/2021
|
Y
|
996
|
QA CASE REVIEW IN-HOME CASE NARRATIVE
|
1865 kb
|
10/05/2021
|
Y
|
997
|
QA CASE REVIEW SUPERVISOR FOSTER CARE CASE QUESTIONNAIRE
|
1289 kb
|
10/05/2021
|
Y
|
998
|
QA CASE REVIEW SUPERVISOR IN-HOME CASE QUESTIONNAIRE
|
1288 kb
|
10/05/2021
|
Y
|
999
|
COMMUNITY-BASED BEHAVIORAL HEALTH PROG PARTICIPANT ELIGIBIL
|
974 kb
|
03/03/2021
|
Y
|
1000
|
VAPS EMERGENCY FUNDS APPLICATION
|
1723 kb
|
10/11/2021
|
Y
|
1001
|
VAPS EMERGENCY FUNDS PROVIDER BILLING
|
1291 kb
|
12/28/2021
|
Y
|
1004
|
RECOVERY HOUSING PROGRAM ASSISTANCE PROVIDER APPLICATION
|
981 kb
|
05/24/2022
|
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
|
1020
|
LICENSE TO PROVIDE ADULT FOSTER CARE
|
196 kb
|
05/03/2019
|
Y
|
1033
|
FOSTER CHILD TRAVEL AUTHORIZATION
|
1288 kb
|
04/29/2021
|
Y
|
1037
|
LICENSING PACKET - FOSTER CARE FOR CHILDREN
|
2363 kb
|
03/10/2022
|
Y
|
1038
|
FOSTER PARENT POLICY AND STANDARD REVIEW
|
1022 kb
|
03/25/2022
|
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
|
898 kb
|
01/13/2022
|
Y
|
1058
|
LICENSE TO PROVIDE RES HABILITATION & COMMUNITY SUPPORTS
|
196 kb
|
05/17/2022
|
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
|
1132
|
OPTIONS COUNSELING (OC) ACTION PLAN
|
1285 kb
|
05/13/2021
|
Y
|
1134
|
TRANSITION ASSISTANCE REQUEST-NDSH/COMMUNITY TRTMNT SETTING
|
1453 kb
|
12/22/2021
|
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
|
1172
|
REQUEST FOR AN ADMINISTRATIVE HEARING
|
394 kb
|
05/11/2022
|
Y
|
1177
|
REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS
|
1037 kb
|
02/15/2022
|
Y
|
1188
|
ADULT QUESTIONNAIRE
|
1183 kb
|
03/22/2022
|
Y
|
1189
|
CHILD/ADOLESCENT QUESTIONNAIRE
|
1237 kb
|
03/24/2022
|
Y
|
1190
|
SCREENING-TRIAGE REFERRAL WITH INTEGRATED ASSESSMENT
|
1060 kb
|
04/06/2022
|
Y
|
1235
|
VISITOR SIGN-IN LOG
|
1285 kb
|
01/28/2020
|
Y
|
1257
|
LICENSING CHECKLIST - SCHOOL AGE CHILD CARE
|
2238 kb
|
05/18/2021
|
Y
|
1259
|
CHILD CARE PROVIDER STAFFING
|
1289 kb
|
12/02/2020
|
Y
|
1265
|
PERSON CENTERED PLAN OF CARE-HCBS
|
1730 kb
|
05/04/2022
|
Y
|
1266
|
TRANSITION SERVICES
|
1723 kb
|
04/06/2022
|
Y
|
1267
|
RISK ASSESSMENT AND HEALTH AND SAFETY PLAN
|
1302 kb
|
04/04/2022
|
Y
|
1269
|
CHILD CARE CONCERN
|
1291 kb
|
06/01/2021
|
Y
|
1276
|
EARLY CHILDHOOD SERVICES UNNANOUNCED REVIEW
|
1320 kb
|
05/14/2021
|
Y
|
1296
|
CONTRACT TO PROVIDE PRIMARY CARE CASE MANAGEMENT SERVICES
|
513 kb
|
02/07/2022
|
Y
|
1297
|
FINGERPRINT VERIFICATION
|
355 kb
|
07/11/2018
|
Y
|
1299
|
GROUP ADDRESS UPDATE
|
317 kb
|
06/03/2021
|
Y
|
1302
|
REQUEST TO ADD/CHANGE TAXONOMY
|
731 kb
|
06/02/2021
|
Y
|
1304
|
FOUR-YEAR OLD PROGRAM APPROVAL
|
1290 kb
|
03/23/2022
|
Y
|
1330
|
REQUEST TO ADD AN AFFILIATION
|
421 kb
|
06/03/2021
|
Y
|
1331
|
PROVIDER TERMINATION
|
431 kb
|
06/03/2021
|
Y
|
1410
|
ND MEDICAL ACUITY TIER RATE ADD-ON PROVIDER SUBMISSION
|
929 kb
|
10/22/2020
|
Y
|
1414
|
DEVELOPMENTAL DISABILITIES QUARTERLY PROGRESS SUMMARY
|
1291 kb
|
07/09/2019
|
Y
|
1415
|
ND MEDICAL ACUITY TIER RATE ADD-ON SECONDARY ASSESSMENT
|
2600 kb
|
10/16/2020
|
Y
|
1422
|
LICENSING CHECK LIST - FAMILY CHILD CARE
|
1770 kb
|
05/14/2021
|
Y
|
1423
|
LICENSING CHECKLIST - CHILD CARE CENTER
|
2249 kb
|
05/14/2021
|
Y
|
1424
|
LICENSING CHECKLIST - PRESCHOOL
|
2236 kb
|
05/14/2021
|
Y
|
1425
|
LICENSING CHECKLIST - GROUP CHILD CARE
|
2242 kb
|
05/14/2021
|
Y
|
1426
|
CHILD CARE RECORD
|
438 kb
|
05/11/2022
|
Y
|
1433
|
NORTH DAKOTA EARLY INTERVENTION-PUBLIC (MEDICAID) ACCESS
|
905 kb
|
05/12/2021
|
Y
|
1467
|
SPED EXSPED INDIVIDUAL CARE PLAN
|
935 kb
|
01/29/2019
|
Y
|
1469
|
EARLY CHILDHOOD SERVICES ADVISORY BOARD APPLICATION
|
929 kb
|
04/20/2022
|
Y
|
1477
|
DEPT CMS FACILITIES COVID-19 VACCINATION RELIGIOUS EXEMPTION
|
903 kb
|
03/22/2022
|
Y
|
1505
|
1915(I) REQUEST FOR SERVICE PROVIDER
|
921 kb
|
07/07/2021
|
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/PROG MANAGER ENVIRONMENTAL SCAN CHECKLIST
|
2112 kb
|
01/14/2022
|
Y
|
1560
|
DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY
|
909 kb
|
02/17/2021
|
Y
|
1595
|
SELF-DECLARATION PROVIDER REVIEW
|
1900 kb
|
05/14/2021
|
Y
|
1596
|
CHILD CARE EMERGENCY CLOSURE AND RELOCATION REPORT
|
1288 kb
|
11/16/2021
|
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
|
969 kb
|
12/03/2021
|
Y
|
1604
|
REQUEST TO BE A QSP FOR FAMILY HOME CARE
|
811 kb
|
11/22/2021
|
Y
|
1605
|
INDIVIDUAL REQUEST TO BE A QSP/AFC PROVIDER
|
897 kb
|
12/03/2021
|
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
|
09/15/2021
|
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
|
1615
|
VAPS QUALITY ASSURANCE REVIEW TOOL - INTAKE
|
1364 kb
|
12/03/2021
|
Y
|
1616
|
VAPS QUALITY ASSURANCE REV TOOL-INVESTIGATION-CLOSED CASES
|
1363 kb
|
03/03/2022
|
Y
|
1617
|
VAPS QUALITY ASSURANCE REVIEW TOOL-INVESTIGATION-OPEN CASES
|
1361 kb
|
03/03/2022
|
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
|
1647
|
HCBS NOTICE OF DENIAL OR TERMINATION
|
318 kb
|
05/04/2022
|
Y
|
1682
|
HEALTH AND SAFETY GRANT
|
1499 kb
|
03/31/2022
|
Y
|
1683
|
TECHNOLOGY GRANT
|
1458 kb
|
03/31/2022
|
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
|
1728
|
APPLICATION FOR CERTIFICATION OF SHELTER CARE PROGRAM
|
960 kb
|
12/06/2021
|
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
|
1780
|
TREATMENT FOSTER CARE EXTENSION REQUEST
|
911 kb
|
04/26/2022
|
Y
|
1781
|
EXTENSION REQUEST FOR SHELTER CARE SERVICES BEYOND 7 DAYS
|
936 kb
|
04/07/2022
|
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
|
1803
|
SUBSIDIZED ADOPTION AGREEMENT
|
1505 kb
|
05/19/2022
|
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
|
1830
|
FEDERAL IV-E GUARDIAN ASSIST PROG CASE PLAN REQUIREMENTS
|
1288 kb
|
04/26/2021
|
Y
|
1831
|
GUARDIANSHIP ASSISTANCE PROGRAM (GAP) ANNUAL REVIEW
|
924 kb
|
04/26/2021
|
Y
|
1832
|
STATE FUNDED GUARDIANSHIP ASSISTANCE PROGRAM (GAP) AGREEMENT
|
905 kb
|
04/26/2021
|
Y
|
1833
|
FEDERAL IV-E GUARDIANSHIP ASSISTANCE PROGRAM (GAP) AGREEMENT
|
926 kb
|
01/03/2022
|
Y
|
1834
|
GUARDIANSHIP ASSISTANCE PROGRAM (GAP) REQUEST
|
940 kb
|
04/26/2021
|
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
|
APPLICATION FOR DUI INSTRUCTOR CERTIFICATION/RECERTIFICATION
|
935 kb
|
03/11/2022
|
Y
|
1909
|
APPLICATION FOR HEALTH COVERAGE AND HELP PAYING COSTS
|
3874 kb
|
03/02/2022
|
Y
|
1910
|
WORK READINESS ASSESSMENT QUESTIONNAIRE
|
6164 kb
|
10/02/2013
|
Y
|
1941
|
LICENSING HOME STUDY RENEWAL-FOSTER CARE FOR CHILDREN
|
808 kb
|
03/16/2022
|
Y
|
1944
|
REQUEST FOR USE OF FPLS FOR CHILD WELFARE SERVICES
|
937 kb
|
06/08/2021
|
Y
|
1948
|
IRS SAFEGUARD REVIEW REPORT
|
1046 kb
|
03/22/2019
|
Y
|
1955
|
PARTICIPANT RISK AGREEMENT (MFP)
|
905 kb
|
12/01/2021
|
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
|
DEPARTMENT OWNED MOBILE DEVICE REQUEST & AGREEMENT
|
996 kb
|
05/06/2022
|
Y
|
1971
|
PERSONALLY OWNED DEVICE REQUEST & AGREEMENT
|
990 kb
|
05/06/2022
|
Y
|
1973
|
REQUEST FOR ELEC COMMUNICATION OF PHI BY UNENCRYPTED MEANS
|
925 kb
|
05/06/2022
|
Y
|
1974
|
REQUEST FOR ELECTRONIC COMM OF NON PHI BY UNENCRYPTED MEANS
|
925 kb
|
05/06/2022
|
Y
|
1976
|
ASSISTIVE TECHNOLOGY AUTHORIZATION-AUTISM WAIVER
|
322 kb
|
11/30/2018
|
Y
|
1977
|
REQUEST FOR CONFIDENTIAL COMMUNICT BY ALTERNATE MEANS OR LOC
|
964 kb
|
05/06/2022
|
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
|
500 kb
|
05/28/2021
|
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
|
369 kb
|
01/10/2022
|
Y
|
60680
|
ELIGIBILITY AND LEVEL OF SUPPORT RECOMMENDATIONS (VABS)
|
340 kb
|
11/30/2018
|
Y
|
60869
|
SCHOOL DISTRICT PRE-KINDERGARTEN PROGRAM APPROVAL
|
917 kb
|
11/04/2021
|
Y
|