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Health and Human Services - Department of - Public Form(s)

SFNTitleSizeDateFillable
2 FFATA CERTIFICATION 900 kb 03/30/2022 Y
3 EBT SECOND PARTY REVIEW REPORT 947 kb 06/18/2024 Y
9 MEDICAID REHAB SERVICES PROVIDER ENROLLMENT ATTESTATION 945 kb 01/09/2024 Y
11 LIHEAP EMERGENCY DOCUMENTATION 1511 kb 08/29/2023 Y
15 HOME HEALTH EXTENDED HOME HEALTH REQUEST FOR SERV AUTHORIZAT 248 kb 06/05/2023 Y
20 SUSPECTED FRAUD REFERRAL 534 kb 09/07/2017 Y
21 TRANSMITTED BETWEEN UNITS 933 kb 07/11/2024 Y
23 APPLICATION FOR APPROVAL FOR RELATIVE CHILD CARE PROVIDER 977 kb 01/26/2023 Y
29 CROSSROADS PROGRAM APPLICATION 958 kb 05/01/2024 Y
45 NOTICE OF CHANGE 866 kb 06/28/2024 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 951 kb 05/08/2024 Y
61 HEALTH TRACKS COMPREHENSIVE ORTHODONTIC SCREENING 372 kb 01/10/2022 Y
62 EMERGENCY ASSISTANCE APPLICATION 1012 kb 08/15/2023 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 1063 kb 10/18/2022 Y
78 REQUEST FOR PURCHASE 1475 kb 06/18/2024 Y
79 SUBSTANCE USE DISORDER SERVICE AUTHORIZATION REQUEST 474 kb 06/04/2021 Y
91 REVOCATION OF AUTHORIZATION TO DISCLOSE INFORMATION 907 kb 05/31/2023 Y
94 SECURITY REQUEST FOR ACCESS TO DEVELOPMENTAL DISABILITIES SY 917 kb 02/13/2023 Y
128 ND FAMILY CAREGIVER SUPPORT PROGRAM PROVIDER AGREEMENT 963 kb 03/21/2023 Y
132 PHYSICIAN STATEMENT FOR MEDICAID TEMPORARY STAY REVIEW 913 kb 01/26/2023 Y
133 QUALIFIED RESIDENTIAL TREATMENT PROGRAM (QRTP) 908 kb 06/19/2024 Y
135 ND FAMILY CAREGIVER SUPPORT PROVIDER SERV LOG-INDIVIDUAL 933 kb 11/08/2023 Y
136 PLAN OF CORRECTION HCBS SURVEY 2070 kb 02/13/2023 Y
143 CIVIL RIGHTS COMPLAINT 936 kb 01/27/2023 Y
151 SCSEP CONFIDENTIAL STATEMENT OF INCOME 972 kb 05/01/2024 Y
152 CHILD SUPPORT VERIFICATION 108 kb Y
155 SCSEP TRAINING SITE APPLICATION 922 kb 08/09/2023 Y
156 SENIOR COMMUNITY SERVICE EMPLOYMENT PROGRAM (SCSEP) TRAINING 1058 kb 03/09/2023 Y
161 DIRECT DEPOSIT ENROLLMENT AND AUTHORIZATION 938 kb 06/25/2024 Y
162 REQUEST FOR HEARING 920 kb 05/09/2023 Y
164 SUBRECIPIENT RISK ASSESSMENT CHECKLIST-HUMAN SERVICE GRANTS 943 kb 03/22/2024 Y
165 CAREGIVER OPTION PLAN-FAMILY CAREGIVER SUPPORT PROGRAM 1250 kb 08/30/2023 Y
166 ADA CONSULTATION AND TECHNICAL ASSISTANCE 900 kb 06/25/2024 Y
168 NORTH DAKOTA MEDICAID PROVIDER APPEAL 910 kb 05/11/2023 Y
170 TAXI TRANSPORTATION VOUCHER 758 kb 04/19/2023 Y
171 FOSTER PROGRAM SUBSIDIZED EMPLOYMENT AGREEMENT 906 kb 07/10/2024 Y
172 IN-HOME SUPPORT APPLICATION 1002 kb 05/01/2024 Y
175 INDIVIDUAL REQUEST TO BE A QSP FOR RESPITE CARE 1136 kb 07/10/2024 Y
177 MMIS ATTACHMENT COVER SHEET 908 kb 06/26/2024 Y
180 APPLICATION FOR VOCATIONAL REHABILITATION SERVICES 969 kb 02/22/2024 Y
185 AWARE ND APPLICATION SUPPLEMENT 1048 kb 02/22/2024 Y
187 MEDICAL EXPENSE WORKSHEET 1494 kb 02/13/2023 Y
199 DISQUALIFYING TRANSFER WORKSHEET 1471 kb 07/08/2024 Y
200 ASSET ASSESSMENT 1096 kb 09/08/2017 Y
201 RELATIVE FAMILY FACT FINDING 1726 kb 11/28/2022 Y
217 SCSPE FAMILY SIZE THIRD PARTY ATTESTATION 953 kb 01/10/2023 Y
219 SCSEP SUPERVISOR'S VOLUNTARY IN-KIND WAGE FUNDING STATEMENT 917 kb 05/18/2023 Y
222 SCSEP SELF-ATTESTATION 994 kb 03/14/2023 Y
223 FIRE INSPECTION CERTIFICATION 1456 kb 05/01/2023 Y
224 PRIVATE DUTY NURSING SERVICE AUTHORIZATION 917 kb 06/25/2024 Y
225 NDFCSP RURAL DIFFERENTIAL RATE AUTHORIZATION 918 kb 08/30/2023 Y
226 PERSON CENTERED SERVICE PLAN - SKILLED NURSING FACILITY 1736 kb 02/13/2023 Y
227 TRANSITION SERVICES - SKILLED NURSING FACILITY 1721 kb 06/07/2022 Y
228 WORKERS WITH DISABILITIES REPORT-PART II 1105 kb 07/02/2024 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
232 SCSEP UNSUBSIDIZED EMPLOYMENT 963 kb 06/05/2023 Y
234 INSURANCE COVERAGE STATEMENT 910 kb 02/13/2023 Y
235 CRIMINAL OFFENSE CONVICTION STATEMENT 1296 kb 02/13/2023 Y
236 FINANCIAL DISCLOSURE STATEMENT 903 kb 02/13/2023 Y
239 SCSEP ORIENTATION VERIFICATION 963 kb 07/03/2023 Y
242 SCSEP PRE-APPLICATION QUESTIONNAIRE 935 kb 09/01/2023 Y
243 ND DRIVERS LICENSE VERIFICATION FOR STATE FLEET OPERATORS 919 kb 02/01/2022 Y
245 SCSEP INDIVIDUAL EMPLOYMENT PLAN 915 kb 02/07/2024 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
251 SCSEP CO-ENROLLMENT IN OTHER PROGRAM SERVICES 912 kb 04/09/2024 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 625 kb 11/07/2022 Y
270 REQUEST FOR REPLACEMENT DUE TO LOSS OF SNAP BENEFITS 929 kb 06/21/2023 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
300 VERIFICATION OF PUBLIC ASSISTANCE INCOME 930 kb 04/24/2024 Y
303 SNAP GROUP LIVING ARRANGEMENT & DRUG/ALCOHOL TRTM EXIT NOTIF 381 kb 03/10/2016 Y
306 CUSTODIAL TEAM MEETING DOCUMENTATION 1000 kb 03/22/2024 Y
308 MEDICAID & BASIC CARE ASSISTANCE PROGRAM AGREEMENT 175 kb 07/25/2017 Y
323 JOBS STATUS OF CHANGE 912 kb 02/13/2023 Y
327 FAMILY FOSTER CARE HOME CLAIM OF PROPERTY DAMAGE 987 kb 09/20/2023 Y
331 NDFCSP NOTICE OF SERVICE DENIAL OR CLOSURE 918 kb 08/30/2023 Y
332 REQUEST FOR PROVIDER LISTING ON THE ADRL) 909 kb 11/03/2023 Y
336 PRESCRIBER TRANSFER REQUEST 440 kb 08/21/2019 Y
339 MONTHLY CASE MANAGEMENT BILLING AND REPORTING 1482 kb 03/21/2024 Y
344 THERAPEUTIC PET OR SERVICE ANIMAL REQUEST 907 kb 11/08/2019 Y
348 COMPELLING REASONS FOR CHILD'S BEST INTEREST 1295 kb 11/22/2022 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
354 CHILD CARE WORKFORCE BENEFIT VERIFICATION 925 kb 06/13/2024 Y
356 AUTHORIZATION TO TRANSFER BACKGROUND CHECK RESULTS - EARLY C 929 kb 08/04/2023 Y
361 FIRE SAFETY SELF DECLARATION AGENCY/INDIVIDUAL FOSTER HOME 1560 kb 12/06/2019 Y
363 REQUEST FOR VERIFICATION OF LIFE INSURANCE POLICY INFO 931 kb 02/13/2023 Y
368 VERIFICATION OF EMPLOYMENT 959 kb 04/11/2023 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
375 AUTHOR TO TRANSFER BACKGROUND CHECK RESULTS-EARLY CHILDHOOD 928 kb 09/21/2023 Y
378 CHANGE REQUEST 972 kb 04/18/2023 Y
383 SERIOUS ACCIDENT INJURY OR ILLNESS REPORT 935 kb 12/15/2020 Y
384 SNAP QUARTERLY REPORT OF FRAUD CONTROL ACTIVITIES 794 kb 07/27/2023 Y
386 ND MEDICAID HPE ENTITY AUTHORIZATION OF DESIGNEE 633 kb 01/06/2016 Y
387 ICPC SUPERVISION REPORT 900 kb 11/17/2022 Y
393 MFCU CLINICAL CRITERIA 596 kb 04/09/2008 Y
394 CHILDREN WITH MEDICALLY FRAGILE NEEDS APPLICATION 424 kb 03/09/2018 Y
395 ICPC FINANCIAL AND MEDICAL PLAN 933 kb 11/17/2022 Y
399 UNLICENSED CAREGIVER HOME STUDY 1154 kb 10/31/2023 Y
401 KINSHIP - ND ALLOWANCE APPLICATION 1211 kb 10/16/2023 Y
403 KINSHIP - ND ALLOWANCE VERIFICATION 948 kb 05/13/2024 Y
405 APPLICATION FOR ASSISTANCE 4515 kb 05/29/2024 Y
408 KINSHIP - ND KINSHIP NAVIGATION SERVICES APPLICATION 1181 kb 10/16/2023 Y
410 PRELIMINARY AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICE 928 kb 06/23/2021 Y
413 INDIVIDUAL INDIAN MONIES ACCOUNT 946 kb 02/13/2023 Y
414 SUBSIDIZED EMPLOYMENT AGREEMENT 273 kb 08/17/2012 Y
423 KINSHIP PLACEMENT/AGREEMENT 954 kb 01/04/2024 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 947 kb 01/30/2023 Y
438 INCIDENT REPORT 1294 kb 12/15/2020 Y
443 NOTICE OF RIGHT TO CLAIM "GOOD CAUSE" 920 kb 02/13/2023 Y
445 FAMILY EVACUATION DISASTER PLAN 928 kb 02/06/2023 Y
446 REQUEST TO CLAIM "GOOD CAUSE" 889 kb 02/13/2023 Y
447 EXCEPTION FOR SUBMITTING ELECTRONIC CLAIMS 910 kb 11/27/2023 Y
451 ELIGIBILITY REPORT ON DISABILITY INCAPACITY 466 kb 07/10/2023 Y
452 APPLICATION FOR A LICENSE TO OPERATE AN ASSISTED LIVING FACI 485 kb 09/22/2022 Y
455 PRESENT DANGER PLAN 917 kb 03/03/2023 Y
462 REQUEST FOR APPEAL CA/N ASSESSMENT DECISION/TIER DESIGNATION 913 kb 06/04/2024 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 ASSESSMENT 974 kb 05/23/2023 Y
480 HOME-DELIVERED MEAL PROGRAM ASSESSMENT 1012 kb 05/24/2023 Y
481 SERVICE LIMITS SERVICE AUTHORIZATION REQUEST 931 kb 03/20/2024 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 932 kb 08/30/2023 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
499 AFFIDAVIT OF MAILING 900 kb 01/31/2024 Y
509 OUT OF STATE/OUT OF NETWORK ENROLLMENT CLARIFICATION 148 kb 06/02/2021 Y
511 MEDICAL PROCEDURE/DEVICE/DRUG SERVICE AUTHORIZATION REQUEST 931 kb 06/04/2024 Y
514 LEVEL II PREADMISSION AND RESIDENT REVIEW ID/RC 930 kb 02/13/2023 Y
517 CHILD CARE EVACUATION DISASTER PLAN 925 kb 01/31/2024 Y
527 GENETIC TESTING SERVICE AUTHORIZATION REQUEST 566 kb 07/14/2020 Y
529 APPLICATION: LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 1179 kb 09/21/2023 Y
530 ELIGIBILITY AND BENEFIT WORKSHEET ENERGY 887 kb 11/23/2022 Y
533 NOTICE OF DENIAL OR TERMINATION OF DEMONSTRATION SERVICES 937 kb 09/07/2022 Y
534 HEALTH CARE IFORMATION FOR PARENTS (CHILDFIND - CARD) 1218 kb 08/10/2023 Y
541 APPLICATION TO PROVIDE AGENCY ADULT FOSTER CARE 399 kb 12/06/2019 Y
542 TRANSITION ASSISTANCE REQUEST 1468 kb 02/06/2024 Y
544 ND TRANSITION AND DIVERSION SERV PILOT NOTICE OF DENIAL/TERM 920 kb 06/03/2024 Y
546 LIFESPAN RESPITE CARE GRANT PROVIDER SERVICE LOG 1299 kb 01/13/2023 Y
548 LIFESPAN RESPITE CARE GRANT EMERGENCY RESPITE CARE APP 1739 kb 11/01/2023 Y
553 CHILDREN'S REGIONAL REVIEW TEAM - INITIAL TEAM REVIEW 1300 kb 02/13/2023 Y
558 COORDINATED SERVICES PROGRAM (CSP) PROVIDER SELECTION 263 kb 10/14/2020 Y
559 LIFESPAN RESPITE CARE GRANT RESPITE PROVIDER AGREEMENT 959 kb 01/13/2023 Y
560 ASSIGNMENT OF BENEFITS 911 kb 02/13/2023 Y
566 MEDICAID QUESTIONNAIRE AND ASSIGNMENT 744 kb 09/03/2015 Y
568 PASRR LEVEL II EVALUATION FOR ID RELATED CONDITION 2183 kb 10/13/2023 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 1299 kb 11/22/2022 Y
575 BEST IN CLASS APPLICATION 1032 kb 01/29/2024 Y
576 EPCS PROVIDER TRAINING PROCEDURE AGREEMENT 957 kb 06/05/2024 Y
582 BEST IN CLASS CONTINUATION INTEREST APPLICATION 1037 kb 11/24/2023 Y
583 ND MEDICAID/ELECTRONIC REMITTANCE ADVICE (835) ENROLLMENT 685 kb 08/04/2022 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 FOSTER HOME FOR ADULTS 1369 kb 10/06/2022 Y
590 RELICENSING STUDY - AGENCY FOSTER HOME FOR ADULTS 1380 kb 03/10/2023 Y
591 OPIOID TREATMENT PROGRAM LICENSE APPLICATION 2052 kb 08/28/2020 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 902 kb 02/14/2023 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 985 kb 01/12/2024 Y
620 NON-EMERGENT MEDICAL TRANSPORTATION 1109 kb 01/18/2024 Y
626 DETERMINE IF A CONTRACT REQUIRES BBA AND A QSO AGREEMENT 852 kb 10/20/2022 Y
630 FOSTER CARE PLACEMENT NOTIFICATION 1023 kb 12/20/2023 Y
631 CORRECTION OR INFORMATION CLAIM FORM LETTER 1901 kb 09/26/2022 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 CARE SETTINGS EXPERIENCE INTERVIEW 1673 kb 03/27/2023 Y
640 VERIFICATION OF PARTICIPATION IN ARSEN PROGRAM 1292 kb 08/02/2022 Y
641 TITLE IV-E TITLE XIX APPLICATION - FOSTER CARE 2463 kb 01/04/2023 Y
642 TITILE IV-E/TITLE XIX INCOME/ASSET REPORT 939 kb 11/16/2022 Y
643 NURSE MGMT AGREEMENT/NPOC INSTRUCT FOR ATTENDANT CARE SERV 311 kb 11/29/2016 Y
648 MEDICATION UNIT LICENSE APPLICATION 2051 kb 09/02/2020 Y
649 NORTH DAKOTA TRANSITION AND DIVERSION SERVICES PILOT PROJECT 1037 kb 01/31/2024 Y
650 ND PEER SUPPORT SPECIALIST RECERTIFICATION APPLICATION 919 kb 03/01/2022 Y
651 EXCEPTIONAL CIRCUMSTANCES IN HIRING-ND EARLY INTERVENTION 1295 kb 02/14/2023 Y
653 MEDICAID PROVIDER ELECTRONIC WEB-FILE TRANSFER REGISTRATION 336 kb 02/02/2015 Y
658 NORTH DAKOTA TDPP CONSENT 910 kb 02/01/2024 Y
659 RESPITE HOME EVALUATION 516 kb 12/22/2017 Y
660 NORTH DAKOTA TDPP CASE CLOSURE NOTICE 911 kb 01/31/2024 Y
661 ELECTRONIC FUNDS TRANSFER (EFT) 923 kb 01/12/2024 Y
662 PERSONAL CARE SERVICES PLAN OF CARE & AUTHORIZATION IN A LIC 978 kb 07/08/2024 Y
664 ADRL FLEX TRANSITION AND INSTITUTIONAL DIVERSION SERV AGREE 953 kb 07/10/2023 Y
665 CERTIFIED PEER SUPPORT SPECIALIST FORMAL COMPLAINT 1451 kb 07/18/2022 Y
669 INITIAL LICENSING STUDY-ADULT FOSTER CARE 1374 kb 10/28/2020 Y
671 MEDICAID PROGRAM QUALIFIED SERVICE PROVIDER (QSP) AGREEMENT 969 kb 12/12/2023 Y
676 ADD NEW RECORD TO MMIS ELIGIBILITY FILE-SPED & EX-SPED 406 kb 10/29/2021 Y
680 DVR POTENTIALLY ELIGIBLE DATA COLLECTION TOOL 931 kb 07/02/2020 Y
682 WORKSITE SCREENING FOR VISION IMPAIRMENT 1024 kb 01/30/2023 Y
683 CUSTOMIZED/SUPPORTED EMPLOYMENT TAX CREDIT CERTIFICATION 919 kb 05/09/2023 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 MFP NURSING ASSESSMENT BILLING WORKSHEET 925 kb 12/13/2022 Y
704 AUTHORIZATION TO PROVIDE (MFP) NURSING ASSESSMENT 904 kb 09/09/2022 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
710 HEALTH TRACKS REFERRAL AND REQUEST FOR INFORMATION 296 kb 05/11/2020 Y
715 NORTH DAKOTA TDPP SERVICE AUTHORIZATION 937 kb 07/03/2024 Y
716 SHS AUTHORIZATION TO DISCLOSE INFORMATION 1490 kb 08/07/2023 Y
717 NORTH DAKOTA TDPP BILLING WORKSHEET 944 kb 01/31/2024 Y
718 PCARD RECORD 1298 kb 03/15/2023 Y
725 REQEUST FOR ACCOUNTING OF DISCLOSURES 917 kb 05/31/2023 Y
734 PCARD TRANSMITTAL COVER SHEET 894 kb 02/22/2023 Y
735 DIVERSION ASSISTANCE SCREENING TOOL 192 kb 08/17/2012 Y
736 CONTROLLED SUBSTANCE AGREEMENT 772 kb 04/26/2024 Y
739 AUTHORIZATION TO PROVIDE COMPANIONSHIP SERVICES 1371 kb 12/19/2023 Y
740 COMPANIONSHIP BILLING WORKSHEET 1300 kb 12/13/2023 Y
741 1915(I) ELIGIBILITY APPLICATION 1086 kb 06/04/2024 Y
743 CHILDRENS' HOSPICE WAIVER APPLICATION 361 kb 06/25/2019 Y
747 AGENCY/INDIVIDUAL FOSTER CARE APPEAL 776 kb 03/10/2023 Y
749 DOCUMENTATION OF COMPETENCY-AGENCY QSP-EMPLOYEE 1118 kb 12/04/2023 Y
750 DOCUMENTATION OF COMPETENCY-INDIVIDUAL QSP 1118 kb 12/04/2023 Y
756 PAYPOINT PRE-AUTHORIZATION 912 kb 07/26/2023 Y
757 FINANCIAL DATA DOCUMENT 928 kb 04/29/2024 Y
758 FACE AND STATUS SHEET 599 kb 08/07/2023 Y
760 TERMINATION OF SPECIAL HEALTH SERVICES 920 kb 08/07/2023 Y
762 ORTHODONTICS REPORT 924 kb 08/07/2023 Y
763 REPORT OF TERMINATION OF ADOPTIVE PLACEMENT 911 kb 01/10/2023 Y
764 NOTICE OF INTENT TO PLACE FOR ADOPTION 908 kb 01/10/2023 Y
765 REQUEST FOR REIMBURSEMENT OF ADOPTION HOME STUDY 924 kb 06/15/2023 Y
766 REEVALUATION OF FINANCIAL ELIGIBILITY 920 kb 08/07/2023 Y
767 MEDICAL DIRECTOR REVIEW RECORD 892 kb 08/10/2023 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 951 kb 05/06/2024 Y
774 MONEY FOLLOWS THE PERSON GRANT RENT GAP ASSIST APPLICATION 1483 kb 09/14/2022 Y
792 OPIOD TREATMENT PROGRAM FEDERAL EXEMPTION REQUEST 659 kb 11/15/2016 Y
793 ADOPTION ASSISTANCE DOCUMENTATION OF NEED 1106 kb 04/26/2024 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 1732 kb 05/31/2024 Y
808 WORKSHEET FOR CLEFT LIP/PALATE CLINICS 898 kb 08/10/2023 Y
811 FREE THROUGH RECOVERY (FTR) PROGRAM PROVIDER APPLICATION 1585 kb 07/19/2023 Y
812 CHILD INTAKE RECORD 416 kb 04/13/2010 Y
814 REQUEST FOR BENEFICIARY SERVICE COVERAGE 306 kb 01/07/2020 Y
816 CHANGE REPORT FOR ADOPTION ASSISTANCE 964 kb 01/19/2023 Y
817 HEALTH INSURANCE COST-EFFECTIVE REVIEW 940 kb 02/13/2023 Y
820 SPED INCOME AND ASSETS 1505 kb 01/26/2024 Y
823 EVACUATION DISASTER PLAN-AGENCY/INDIVIDUAL FOSTER CARE 474 kb 12/06/2019 Y
824 UNIVERSAL APPLICATION 1108 kb 07/01/2024 Y
826 CHILDREN'S TREATMENT SERVICES LOC DETERMINATION CSR 1041 kb 07/01/2024 Y
829 PERSONAL AUTHORIZATION FOR CRIMINAL HISTORY RECORD INFO 983 kb 02/16/2024 Y
830 REQUEST FOR CLIENT SPECIFIC ENDORSEMENT 938 kb 08/07/2023 Y
831 CHILDREN'S TREATMENT SERVICES LOC DETERMINATION-ATTESTATION 977 kb 06/17/2024 Y
833 PATIENT CONSENT FOR TELEMEDICINE ENCOUNTER 336 kb 12/20/2021 Y
836 FINGERPRINT IDENTITY VERIFICATION 905 kb 09/07/2022 Y
839 FOSTER CARE OVERPAYMENT NOTIFICATION 931 kb 11/01/2022 Y
844 IDENTIFIED RELATIVE LICENSE - FAMILY FOSTER HOMES 964 kb 04/01/2024 Y
845 CHILD INFORMATION SHEET 498 kb 05/11/2022 Y
847 PARENTS STATEMENT ON HEALTH OF CHILD 490 kb 07/26/2011 Y
850 INITIAL LICENSING SPECIALIST CHECKLIST FAMILY FOSTER HOMES 974 kb 05/15/2024 Y
851 ANNUAL LICENSING SPECIALIST CHECKLIST FAMILY FOSTER HOMES 976 kb 05/15/2024 Y
852 SENDING STATE EXPEDITED HOME STUDY REQUEST-ICPC 101 924 kb 11/17/2022 Y
854 TITLE IV-E ADOPTION SUBSIDY CERTIFICATION 938 kb 05/09/2024 Y
855 TITLE IV-E ADOPTION SUBSIDY ELIGIBILITY DETERMINATION 955 kb 01/18/2023 Y
856 ADOPTION SUBSIDY AGREEMENT - REVIEW 954 kb 01/11/2023 Y
859 SUBSTANCE ABUSE DISORDER VOUCHER PROGRAM APPLICATION 910 kb 07/03/2023 Y
863 LICENSING CHANGE CHECKLIST-FAMILY FOSTER HOMES 1022 kb 05/15/2024 Y
866 INTERMITTENT RISK ASSESSMENT/EMERGENCY BACK-UP PLAN 1000 kb 02/14/2023 Y
869 TITILE IV-E INITIAL ELIGIBILITY 1030 kb 05/22/2023 Y
870 TITLE IV-E 18+ CONTINUED CARE ELIGIBILITY 1010 kb 05/14/2024 Y
873 TITLE IV-E INCOME CALCULATION WORKSHEET 936 kb 11/01/2022 Y
874 OFFICIAL REQUEST FOR CUSTOMER FINANCIAL RECORDS 925 kb 03/15/2023 Y
875 FALSE CLAIMS EDUCATION CERTIFICATION 323 kb 01/10/2020 Y
880 SUBSTANCE USE DISORDER (SUD) VOUCHER INDIVIDUAL APPLICATION 1034 kb 04/03/2024 Y
882 CROSSROADS SCHOOL EVALUATION 940 kb 09/01/2023 Y
885 STATEMENT OF CASE WORKER 912 kb 11/17/2022 Y
886 APPLICATION FOR CHILD PLACING AGENCY LICENSE (LCPA) 1769 kb 06/15/2023 Y
887 APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL) 1265 kb 09/14/2022 Y
888 PERSONAL AUTHORIZATION CRIM HISTORY INQ-CHILD ADVOCACY CTRS 962 kb 01/23/2023 Y
889 INITIAL HOME STUDY FOSTER CARE FOR CHILDREN 1405 kb 05/14/2024 Y
890 AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO 1490 kb 04/01/2024 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 1057 kb 07/02/2024 Y
895 ADMISSION EXCEPTION REQUEST QRTP 939 kb 09/14/2022 Y
896 DISCHARGE EXCEPTION REQUEST QRTP 921 kb 09/14/2022 Y
898 ANNUAL LICENSING APPLICATION QRTP 2286 kb 09/02/2022 Y
902 FOSTER CARE LICENSING REFERENCE CHECK 787 kb 01/04/2023 Y
903 FOSTER CARE PROVIDER REIMBURSEMENT REQUEST 938 kb 08/22/2023 Y
904 AGREEMENT TO RECEIVE FAMILY FOSTER CARE EXCESS MAINT PAYMENT 922 kb 08/31/2023 Y
905 SERVICE/TECHNOLOGY/PROCEDURE ASSESSMENT 361 kb 03/23/2023 Y
918 SERVICE MANAGEMENT LOG 413 kb 07/07/2017 Y
920 FOSTER CARE - CHILD CARE INVOICE 1474 kb 11/02/2022 Y
921 AASK AUTHORIZATION TO DISCLOSE INFORMATION 922 kb 02/01/2024 Y
922 HUMAN SERVICE ZONE REFERRAL FOR AASK PROGRAM 1013 kb 03/15/2024 Y
923 TRIBAL EXCEPTION REFERRAL FOR AASK PROGRAM 1175 kb 02/16/2024 Y
926 MFP-EMERGENCY BACKUP PLAN 920 kb 09/13/2022 Y
927 AASK PROGRAM CAREGIVER SUMMARY 913 kb 02/01/2024 Y
928 AGREEMENT TO FURNISH SHELTER CARE 940 kb 09/14/2022 Y
929 RESPITE REQUEST AND PROVIDER AGREEMENT 1001 kb 04/01/2024 Y
930 BACKGROUND INFORMATION FOR ADOPTION SERVICES 1.1 Mb 01/09/2023 Y
931 SHELTER CARE PLACEMENT CLAIM 963 kb 04/01/2024 Y
933 REQUEST FOR HIPAA PRIVACY OFFICER REVIEW 933 kb 05/31/2023 Y
934 REQUEST FOR INFORMAL PRIVACY CONFERENCE 930 kb 05/31/2023 Y
936 ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICE 912 kb 06/12/2023 Y
937 NOTICE OF PLACEMENT OF CHILD WITH IMMEDIATE RELATIVE 899 kb 01/08/2023 Y
939 REPORT OF ADOPTION/ADOPTIVE PLACEMENT 1081 kb 07/03/2023 Y
940 SEARCH/DISCLOSURE REQUEST 941 kb 02/07/2023 Y
942 SEARCH/DISCLOSURE NOTIFICATION 915 kb 01/06/2023 Y
945 CERTIFICATION TO THE NORTH DAKOTA HEALTH AND HUMAN SERVICES 919 kb 01/10/2023 Y
946 AFFIDAVIT 907 kb 01/10/2023 Y
947 NOTICE OF INTENT/FINAL INTERNATIONAL ADOPTION DECREE 915 kb 02/06/2023 Y
948 NOTICE OF INTENT 921 kb 02/06/2023 Y
958 HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED 2275 kb 03/07/2024 Y
960 REPORT OF SUSPECTED CHILD ABUSE OR NEGLE 917 kb 07/14/2022 Y
963 TARGETED CASE MANAGEMENT ASSESSMENT 438 kb 07/17/2020 Y
965 INTERSTATE COMPACT ON THE PLACEMENT OF CHILDREN REQUEST 978 kb 11/28/2022 Y
966 IC REPORT ON PLACEMENT STATUS OF CHILD 938 kb 11/23/2022 Y
969 ORIENTATION CERTIFICATION 905 kb 07/28/2021 Y
970 MULTI-AGENCY AUTHORIZATION TO DISCLOSE INFORMATION 1564 kb 10/17/2023 Y
971 SUBSTANCE ABUSE TREATMENT LICENSE APPLICATION 949 kb 10/29/2020 Y
974 PHYSCIAL EXAM VERIFICATION FAMILY FOSTER HOMES 928 kb 04/01/2024 Y
977 SECURITY ACCESS AND PHOTO REQUEST 1456 kb 09/26/2022 Y
980 ADULT PROTECTIVE SERVICES (APS) FORENSIC ACCOUNTING APP 1727 kb 04/17/2023 Y
985 APPLICATION FOR ELIGIBILITY DETERMINATION 1089 kb 09/14/2021 Y
986 COMMUNITY CONNECT PROGRAM PROVIDER APPLICATION 1611 kb 07/19/2023 Y
989 SCSEP ACKNOWLEDGMENT 910 kb 01/27/2023 Y
992 QUALITY ASSURANCE (QA) CASE REVIEW ADOPTION CASE NARRATIVE 1721 kb 11/21/2023 Y
993 QA CASE REVIEW CHILD PROTECTIVE SERVICES CASE NARRATIVE 1715 kb 05/03/2022 Y
995 QA CASE REVIEW FOSTER CARE CASE NARRATIVE 1312 kb 11/21/2023 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 APS EMERGENCY GOODS AND SERVCICES FUNDS APPLICATION 1733 kb 04/17/2023 Y
1001 APS GOODS AND SERVICES FUNDS PROVIDER BILLING 1301 kb 04/17/2023 Y
1004 RECOVERY HOUSING PROGRAM ASSISTANCE PROVIDER APPLICATION 981 kb 09/01/2022 Y
1008 HCBS CASE CLOSURE/TRANSFER NOTICE 911 kb 02/14/2023 Y
1009 HCBS NOTICE OF REDUCTION, DENIAL OR TERMINATION 911 kb 02/14/2023 Y
1010 PROVIDER ASSURANCE TO FEDERAL HOME & COMMUNITY BASED SERVICE 922 kb 02/14/2023 Y
1011 NOTIFICATION OF HCBS SCREENING 901 kb 02/14/2023 Y
1013 APPLICATION TO PROVIDE ADULT FOSTER CARE 1366 kb 10/28/2020 Y
1017 FOSTER CARE LICENSING AMENDMENT REQUEST 1007 kb 05/15/2024 Y
1018 NEW HIRE REPORTING INFORMATION 993 kb 07/10/2023 Y
1019 HEALTH TRACKS/FAMILY SUPPORT REFERRAL 379 kb 06/12/2015 Y
1020 LICENSE TO PROVIDE ADULT FOSTER CARE 687 kb 03/13/2023 Y
1023 FOSTER CARE TRANSPORTATION REIMBURSEMENT BUDGET SHEET 929 kb 11/02/2022 Y
1026 WAIVER OF STATE LODGING RATE 903 kb 10/10/2023 Y
1033 FOSTER CHILD TRAVEL AUTHORIZATION 921 kb 02/06/2023 Y
1037 LICENSING PACKET - FOSTER CARE FOR CHILDREN 1745 kb 04/01/2024 Y
1038 FOSTER PARENT PROVIDER POLICY AND STANDARD REVIEW 1006 kb 05/22/2024 Y
1040 REASONABLE AND PRUDENT PARENTING CONSENT 1024 kb 09/01/2023 Y
1041 CHILD CARE DEATH REPORT 930 kb 12/14/2020 Y
1042 IRREGULAR FOSTER CARE PAYMENTS 920 kb 11/02/2022 Y
1047 APPLICATION FOR SERVICE 908 kb 01/22/2024 Y
1050 OUT OF STATE INQUIRY (DUPLICATE BENEFITS) PARIS MATCH 946 kb 04/18/2023 Y
1058 LICENSE TO PROVIDE RES HABILITATION & COMMUNITY SUPPORTS 196 kb 05/17/2022 Y
1059 AUTHORIZATION TO DISCLOSE INFORMATION 947 kb 06/30/2023 Y
1063 AUTHORIZATION TO DISCLOSE BEHAVIORAL HEALTH INFORMATION 1527 kb 05/25/2023 Y
1065 AUTHORIZATION TO DISCLOSE INFORMATION 1500 kb 05/14/2024 Y
1076 GROWER'S STATEMENT 933 kb 02/13/2023 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 NDHHS DETERMINATION OF SPECIAL NEEDS 929 kb 02/07/2023 Y
1095 TRIAL WORK EXPERIENCE REPORT 1291 kb 02/24/2020 Y
1096 SCSEP PARTICIPANT ORIENTATION RECORD 973 kb 01/10/2023 Y
1100 SCSEP PHYSICAL EXAM WAIVER 928 kb 01/04/2023 Y
1101 MONTHLY PROGRESS SUMMARY 1292 kb 12/06/2019 Y
1103 REQUEST FOR SERVICES 978 kb 08/10/2023 Y
1104 NOTICE OF ACTION REGARDING SPECIAL HEALTH SERVICES COVERAGE 923 kb 08/10/2023 Y
1115 ND MEDICAID TRIBAL CARE COORDINATION FUND ANNUAL REPORT 966 kb 08/25/2023 Y
1123 HOME AND COMMUNITY-BASED SERVICES AUTHORIZING SIGNATURES 952 kb 01/22/2024 Y
1125 COMMUNITY CONNECT PORTAL ACCESS REQUEST AND CONFID AGREEMENT 914 kb 01/10/2023 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
1168 OWNERSHIP CONTROLLING INTEREST AND CONVICTION INFORMATION 890 kb 01/20/2023 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 1051 kb 01/29/2024 Y
1181 CLINIC RESPONSE CARD 1194 kb 08/10/2023 Y
1187 NORTH DAKOTA GLOBAL CLIENT CONSENT 911 kb 01/06/2023 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
1197 CHILDREN WITH COMPLEX NEEDS TRANSITION PLAN AGREEMENT 952 kb 07/08/2024 Y
1202 HOUSING FACILITATION REFERRAL 966 kb 03/30/2023 Y
1212 HOUSING FACILITATOR CONSENT 910 kb 04/03/2023 Y
1220 CHILD CARE ASSISTANCE ATTENDANCE RECORD 916 kb 10/04/2022 Y
1235 VISITOR SIGN-IN LOG 1285 kb 01/28/2020 Y
1266 TRANSITION SERVICES 1723 kb 04/06/2022 Y
1268 QUALIFIED SERVICE PROVIDER (QSP) REFERRAL/REQUEST 1298 kb 05/06/2024 Y
1269 CHILD CARE CONCERN 1291 kb 06/01/2021 Y
1297 FINGERPRINT VERIFICATION 355 kb 07/11/2018 Y
1299 GROUP ADDRESS UPDATE 934 kb 01/12/2024 Y
1302 REQUEST TO ADD/CHANGE TAXONOMY 731 kb 06/02/2021 Y
1304 FOUR-YEAR OLD PROGRAM APPROVAL 938 kb 04/20/2023 Y
1330 REQUEST TO ADD AN AFFILIATION 921 kb 01/12/2024 Y
1331 PROVIDER TERMINATION 921 kb 01/12/2024 Y
1410 ND MEDICAL ACUITY TIER RATE ADD-ON PROVIDER SUBMISSION 938 kb 02/14/2023 Y
1411 DD PROGRAM MANAGEMENT AGE THREE REDETERMINATION 907 kb 02/14/2023 Y
1414 DEVELOPMENTAL DISABILITIES QUARTERLY PROGRESS SUMMARY 1301 kb 02/14/2023 Y
1415 ND MEDICAL ACUITY TIER RATE ADD-ON SECONDARY ASSESSMENT 2610 kb 02/14/2023 Y
1419 SIS & INVENTORY FOR ICAP ASSESSMENT REQUEST 1297 kb 11/29/2023 Y
1426 CHILD CARE RECORD 438 kb 05/11/2022 Y
1431 ND MEDICAL ACUITY TIERS SECONDARY ASSESSMENT - SCORING 1825 kb 02/15/2023 Y
1433 NORTH DAKOTA EARLY INTERVENTION-PUBLIC (MEDICAID) ACCESS 914 kb 02/15/2023 Y
1453 REQUEST FOR DEVELOPMENTAL DISABILITIES GUARDIANSHIP ESTABLIS 1051 kb 02/01/2024 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
1478 NOTICE OF INVALID AUTHORIZATION TO DISCLOSE INFORMATION 921 kb 06/14/2023 Y
1505 1915(I) REQUEST FOR SERVICE PROVIDER 921 kb 07/07/2021 Y
1509 EXTRA SUPERVISION PAYMENT APPROVAL 922 kb 06/13/2024 Y
1510 OTOACOUSTIC EMISSIONS TYMPANOMETRY (OAE/TYMP) SCREENING 906 kb 02/15/2023 Y
1522 DEVELOPMENTAL DISABILITIES VIRTUAL SUPPORT CHECKLIST 1003 kb 11/29/2023 Y
1525 SITUATIONAL ASSESSMENT REPORT 1364 kb 12/18/2019 Y
1531 FINANCIAL DECLARATION 1161 kb 08/31/2023 Y
1543 CRISIS INTAKE 942 kb 06/25/2024 Y
1544 POLICIES AND PROCEDURES CHECKLIST 913 kb 02/15/2023 Y
1545 SANITATION INSPECTION CERTIFICATION 907 kb 02/15/2023 Y
1549 GOVERNANCE STATEMENT 912 kb 05/28/2024 Y
1550 LICENSE TERMINATION REQUEST 1295 kb 02/15/2023 Y
1551 LICENSE APPLICATION CHECKLIST/RESIDENTIAL SERVICES 907 kb 02/15/2023 Y
1552 LICENSE APPLICATION CHECKLIST/DAY SERVICES 908 kb 02/15/2023 Y
1555 PHYSICAL STANDARDS CHECKLIST - GROUP HOME FACILITIES 1109 kb 02/15/2023 Y
1556 PLAN OF CORRECTION 905 kb 02/15/2023 Y
1557 DD PROGRAM ADMIN/PROG MANAGER ENVIRONMENTAL SCAN CHECKLIST 967 kb 02/15/2023 Y
1560 DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY 918 kb 02/15/2023 Y
1573 DEVELOPMENTAL DISABILITIES REFERRAL 937 kb 04/19/2023 Y
1596 CHILD CARE EMERGENCY CLOSURE AND RELOCATION REPORT 1288 kb 11/16/2021 Y
1598 MEDICALLY FRAIL QUESTIONNAIRE 1329 kb 05/30/2024 Y
1602 REQUEST TO BE A QSP FOR FAMILY PERSONAL CARE 1079 kb 05/25/2023 Y
1603 INDIVIDUAL REQUEST TO BE A QUALIFIED SERVICE PROVIDER 1145 kb 05/10/2023 Y
1604 REQUEST TO BE A QSP FOR FAMILY HOME CARE 1077 kb 05/22/2023 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 1649 kb 03/31/2023 Y
1607 RPT OF SUSPECTED VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOIT 790 kb 10/07/2022 Y
1610 VULNERABLE ADULT PROTECTIVE SERVICES INTAKE 1713 kb 10/07/2022 Y
1612 FOSTER CARE VERIFICATION 910 kb 11/18/2022 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 APPLICATION-APPENDIX A 962 kb 09/18/2023 Y
1619 REQUEST TO BE QUALIFIED SERVICE PROVIDER/AFHA 936 kb 04/21/2020 Y
1620 APPLICATION - APPENDIX B 938 kb 09/18/2023 Y
1626 COMMUNITY REHABILITATION PROVIDER REFERRAL 939 kb 06/30/2023 Y
1627 COMMUNITY REHABILITATION PROVIDER SERVICES PLANNING MEETING 973 kb 06/20/2022 Y
1647 HCBS NOTICE OF DENIAL OR TERMINATION 908 kb 01/29/2024 Y
1654 QSP SERVICE AGREEMENT - LIVE IN PAID CAREGIVERS 927 kb 07/01/2024 Y
1682 HEALTH AND SAFETY GRANT 1497 kb 09/07/2022 Y
1683 TECHNOLOGY GRANT 1458 kb 09/07/2022 Y
1694 SEARCH AND COPYING SERVICES RECORDS REQUEST 162 kb Y
1702 QUALIFIED SERVICE PROVIDER (QSP) ACKNOWLEDGEMENT 912 kb 06/18/2024 Y
1703 COMPLIANCE CHECKLIST/ADULT DAY CARE STAND 825 kb 06/12/2023 Y
1720 MULTIDISCIPLINARY CLINIC-FAMILY INTERVIEW 1296 kb 08/10/2023 Y
1728 APPLICATION FOR CERTIFICATION OF SHELTER CARE PROGRAM 975 kb 05/30/2024 Y
1730 HCBS FOR ELDERLY/DISABLED & DEVELOPMENTALLY DISABLED BILLING 124 kb 04/11/2023 Y
1731 MEDICAL TRAVEL/LODGING BILLING 110 kb 07/25/2017 Y
1741 AUTHORIZATION FOR HCBS RATE AUGMENTATION 936 kb 05/13/2024 Y
1758 DEVELOPMENTAL DISABILITIES APPLICATION 907 kb 02/15/2023 Y
1761 APP CONTRACT FOR CHILD SUPPORT SERVICES-NONCUSTODIAL PARENT 916 kb 10/18/2022 Y
1763 REQUEST FOR REIMBURSEMENT/DIRECT SERVICE 728 kb 05/24/2023 Y
1764 TRADITIONAL SELF-DIRECTED DISABILITY SUPPORT APPLICATION 2111 kb 02/15/2023 Y
1781 EXTENSION REQUEST FOR SHELTER CARE SERVICES BEYOND 7 DAYS 936 kb 04/07/2022 Y
1783 HEALTH AND HUMAN SERVICES SINGLE AUDIT CERTIFICATION 939 kb 06/18/2024 Y
1789 HCBS RATE AUGMENTATION BILLING WORKSHEET 953 kb 05/13/2024 Y
1792 SELF-DISCLOSURE OF PREVIOUS CRIMINAL HISTORY 906 kb 02/15/2023 Y
1793 NORTH DAKOTA DD PROVIDER LETTER OF INTENT APPLICATION 1343 kb 02/15/2023 Y
1794 NORTH DAKOTA DEVELOPMENTAL DISABILITIES PROVIDER APPLICATION 978 kb 02/20/2024 Y
1797 ICF/IID MEDICALLY INTENSIVE RATE REQUEST 1302 kb 02/15/2023 Y
1800 EMPLOYMENT READINESS ASSESSMENT 1302 kb 01/10/2024 Y
1802 SIS & ICAP ASSESSMENT PROVIDER CHECKLIST 973 kb 11/30/2023 Y
1803 SUBSIDIZED ADOPTION AGREEMENT 1505 kb 10/04/2022 Y
1810 AUTHORIZATION TO PROVIDE DEVELOPMENTAL DISABILITIES SERVICES 977 kb 01/14/2021 Y
1812 ICF/IID PHYSICIAN CERTIFICATION AND RECERTIFICATION 910 kb 03/15/2023 Y
1815 ASSESSMENT RESULTS 935 kb 11/30/2023 Y
1820 SPED PROGRAM POOL DATA 1328 kb 12/03/2019 Y
1829 LONG TERM CARE OMBUDSMAN PROGRAM COMPLAINT 789 kb 03/30/2023 Y
1830 FEDERAL IV-E GUARDIAN ASSIST PROG CASE PLAN REQUIREMENTS 1297 kb 11/22/2022 Y
1831 GUARDIANSHIP ASSISTANCE PROGRAM (GAP) ANNUAL REVIEW 933 kb 11/22/2022 Y
1832 STATE FUNDED GUARDIANSHIP ASSISTANCE PROGRAM (GAP) AGREEMENT 914 kb 11/22/2022 Y
1833 FEDERAL IV-E GUARDIANSHIP ASSISTANCE PROGRAM (GAP) AGREEMENT 935 kb 11/22/2022 Y
1834 GUARDIANSHIP ASSISTANCE PROGRAM (GAP) REQUEST 949 kb 11/22/2022 Y
1835 OUTLIER REQUEST 1802 kb 12/05/2023 Y
1839 OUT OF SEQUENCE FOR MAJOR LIFE CHANGING EVENT ASSESSMENT REQ 1308 kb 11/30/2023 Y
1842 SCSEP PROGRAM APPLICATION 1062 kb 05/01/2024 Y
1843 CLIENT REGISTRATION (CENTER ADMISSION) 1079 kb 06/03/2024 Y
1853 INDIVIDUAL EMPLOYMENT SUPPORTS OUTLIER REQUEST 922 kb 08/24/2023 Y
1859 DEVELOPMENTAL DISABILITIES INTAKE INTERVIEW 1009 kb 04/13/2023 Y
1862 COMMUNITY TRANSITION SERVICES BUDGET TRAD IID/DD WAIVER 1289 kb 10/16/2020 Y
1865 FOSTER CARE CHILD NEEDS ASSESSMENT AND AGREEMENT 1005 kb 06/18/2024 Y
1870 APPLICATION FOR DUI INSTRUCTOR CERTIFICATION/RECERTIFICATION 935 kb 03/11/2022 Y
1897 AUTHORIZED SIGNATURES 929 kb 03/14/2023 Y
1907 INCLUSION SUPPORT GRANT APPLICATION 918 kb 12/09/2022 Y
1909 APPLICATION FOR HEALTH COVERAGE AND HELP PAYING COSTS 4195 kb 08/09/2023 Y
1910 WORK READINESS ASSESSMENT QUESTIONNAIRE 6164 kb 10/02/2013 Y
1929 INCLUSIVE CARE SUPPORT GRANT REPORT 908 kb 05/13/2024 Y
1930 INCLUSIVE CARE SUPPORT GRANT 947 kb 10/17/2023 Y
1933 MONEY FOLLOWS THE PERSON (MFP) RENTAL ASSISTANCE PROG AGREE 929 kb 06/12/2024 Y
1941 LICENSING ON-SITE VISIT REPORT 903 kb 05/14/2024 Y
1944 REQUEST FOR USE OF FPLS FOR CHILD WELFARE SERVICES 946 kb 11/18/2022 Y
1946 GROW CHILD CARE BUSINESS PLAN 949 kb 02/23/2024 Y
1948 IRS SAFEGUARD REVIEW REPORT 1046 kb 03/22/2019 Y
1950 GROW CHILD CARE BUDGET PAGE AND NARRATIVE 1571 kb 02/23/2024 Y
1951 PROFESSIONAL DEVELOPMENT WORKING GROUP 969 kb 01/08/2024 Y
1953 FACILITY IMPROVEMENT GRANT - ACKNOWLEDGEMENT 923 kb 05/13/2024 Y
1954 FACILITY IMPROVEMENT GRANT WORKSHEET 1583 kb 05/13/2024 Y
1955 PARTICIPANT RISK AGREEMENT (MFP) 905 kb 12/01/2021 Y
1956 MFP TRANSITION ADJUSTMENT SUPPORTS BILLING WORKSHEET 929 kb 12/19/2023 Y
1958 AUTHORIZATION TO PROVIDE MFP TRANSITION ADJUSTMENT SUPPORT S 914 kb 12/13/2022 Y
1965 EARLY CHILDHOOD SPECIAL EDUCATION FAMILY ENGAGEMENT GRANT 949 kb 09/13/2023 Y
1967 OPT OUT OF MAKING INCOME WITHHOLDING PYMTS ELECTRONICALLY 898 kb 10/18/2022 Y
1968 SPECIAL DIFF ASSOCIATION WITH MAKING INCOME WITHOLD ELECT 908 kb 10/18/2022 Y
1969 SPECIAL DIFF WITH REPORTING NEW HIRES ELECTRONICALLY 907 kb 10/18/2022 Y
1970 DEPARTMENT OWNED MOBILE DEVICE REQUEST & AGREEMENT 974 kb 05/13/2024 Y
1971 PERSONALLY OWNED MOBILE DEVICE REQUEST AND AGREEMENT 950 kb 05/13/2024 Y
1973 REQUEST FOR ELEC COMMUNICATION OF PHI BY UNENCRYPTED MEANS 941 kb 10/19/2022 Y
1974 REQUEST FOR ELECTRONIC COMM OF NON PHI BY UNENCRYPTED MEANS 940 kb 10/19/2022 Y
1976 ASSISTIVE TECHNOLOGY AUTHORIZATION-AUTISM WAIVER 1485 kb 05/01/2024 Y
1977 REQUEST FOR CONFIDENTIAL COMMUNICT BY ALTERNATE MEANS OR LOC 963 kb 10/19/2022 Y
1978 REQUEST TO DIRECT ELECTRONIC PHI TO THIRD PARTY 787 kb 06/12/2023 Y
1979 REQUEST TO ACCESS PROTECTED HEALTH INFORMATION (PHI) 936 kb 06/12/2023 Y
1980 REQUEST TO RESTRICT USE & DISCLOSURE OF PHI 939 kb 06/13/2023 Y
1981 REQUEST TO AMEND PROTECTED HEALTH INFORMATION (PHI) 948 kb 06/12/2023 Y
1982 REQUEST TO ACCESS RECORDS AND INFORMATION NON-PROTECTED INFO 928 kb 06/12/2023 Y
1992 RELEASE OF INFORMATION - SEARCH/DISCLOSURE 776 kb 01/09/2023 Y
5531 REQUEST FOR COPY OF DEATH CERTIFICATE 1576 kb 03/12/2024 Y
6739 REPORT OF ADOPTION 957 kb 10/11/2022 Y
8109 APPLICATION FOR REGISTRATION OF CEMETERY 916 kb 10/11/2022 Y
8140 REQUEST FOR CERTIFIED COPY OF BIRTH RECORD 1570 kb 01/03/2024 Y
8148 FUNERAL PRACTITIONER'S MONTHLY REPORTS OF DEATHS 931 kb 05/02/2023 Y
8161 DATA REPORT OF INDUCED TERMINATION OF PREGNANCY 1005 kb 01/11/2024 Y
8175 AFFIDAVIT TO AMEND DEATH CERTIFICATE 898 kb 10/04/2022 Y
8178 APPLICATION FOR DISINTERMENT REINTERMENT 909 kb 04/17/2023 Y
8191 AFFIDAVIT OF PERSONAL KNOWLEDGE OF BIRTH 916 kb 02/28/2023 Y
8618 CLIENT FLOW SHEET 191 kb 04/16/2007 Y
8620 EXAM 992 kb 12/23/2011 Y
8627 MEDICATION PROFILE 150 kb 04/16/2007 Y
8633 MALE VISIT 921 kb 11/29/2011 Y
51061 FEMALE TARGET AND INITIAL HISTORY 1162 kb 11/29/2011 Y
53345 APPLICATION AND LICENSE TO OPERATE A PERPETUAL CARE CEMETERY 956 kb 05/11/2023 Y
58493 PAP SMEAR FLOW SHEET 225 kb 04/16/2007 Y
58645 NORTH DAKOTA DISPOSITION TRANSIT PERMIT 354 kb 12/05/2023 Y
58646 NORTH DAKOTA CERTIFIER'S WORKSHEET FOR DEATH 690 kb 12/05/2023 Y
58647 NORTH DAKOTA FUNERAL PRACTIONERS'S WORKSHEET 624 kb 12/05/2023 Y
58698 AUTHORIZATION TO RECEIVE A CERTIFIED COPY 945 kb 12/23/2019 Y
58707 ND CERTIFIER'S WORKSHEET FOR FETAL DEATH 1255 kb 12/05/2023 Y
58708 ND PARENT'S WORKSHEET FOR FETAL DEATH 760 kb 12/05/2023 Y
59155 INITIAL HISTORY - FEMALE 1280 kb 11/29/2011 Y
59323 CRIBS FOR KIDS PROGRAM EDUCATION AND SCREENING 1434 kb 09/21/2023 Y
59324 CRIBS FOR KIDS PROGRAM COMPLIANCE QUESTIONNAIRE 880 kb 09/15/2023 Y
59499 NDQUITS REFERRAL 780 kb 09/14/2022 Y
59996 COMPLIANCE REPORT OF INDUCED TERMINATION OF PREGNANCY 935 kb 01/10/2024 Y
60025 REFUSAL OF NEWBORN BLOOD SPOT SCREENING TEST 777 kb 08/10/2023 Y
60183 BIRTH RECORD AMENDMENT APPLICATION 985 kb 01/03/2024 Y
60603 GENERAL INCIDENT REPORT 1170 kb 02/15/2017 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 1473 kb 05/01/2024 Y
60680 ELIGIBILITY AND LEVEL OF SUPPORT RECOMMENDATIONS (VABS) 340 kb 11/30/2018 Y
60804 AUTISM SPECTRUM DISORDER REPORT 1083 kb 04/24/2019 Y
60953 CRIBS FOR KIDS PROGRAM HOLD HARMLESS AGREEMENT 852 kb 09/21/2023 Y
61643 REQUEST FOR CERTIFIED COPY OF A FETAL DEATH RECORD 1562 kb 01/03/2024 Y
61645 REQUEST FOR CERTIFIED COPY OF AN ACKNOWLEDGMENT OF PATERNITY 1604 kb 01/03/2024 Y
61754 PARENT CONSENT FOR PUBLIC HEALTH HYGIENCE SERVICES 952 kb 01/14/2020 Y
62192 HEALTH AND WELFARE/CHAIN OF CUSTODY 945 kb 07/20/2022 Y
62230 VACCINATION ASSISTANCE REQUEST 173 kb 09/28/2022 Y