Forms

Because of the Adobe forms technology, it is highly recommended that Internet Explorer 11 or later is used for accessing PDF forms whenever possible. Microsoft Edge is not recommended or supported. If you must use Chrome or Firefox, please follow the instructions listed below.

Adobe PDF Viewer

PDF forms require an Adobe PDF Viewer browser plug-in. The latest versions of Chrome and Firefox do not support this technology by default. Some additional configurations need to be made to these browsers for them to work properly. Depending on your version of Chrome or Firefox, the instructions may vary slightly. When possible, use Internet Explorer 11 or higher. Adobe Reader needs to be installed on your machine. After Adobe Reader is installed, proceed with the instructions below for your specific browser.

Chrome

Replace the Chrome built in PDF viewer so that you can open, view, and save PDF's without issues.

  • Type into the address window of Chrome browser: chrome://settings/content
  • Scroll down to “Additional content settings” and click the drop-down arrow
  • Select the right arrow next to “PDF documents”
  • Slide the slider to the right for “Download PDF files instead of automatically opening them in Chrome”
  • Click on a form number hyperlink
  • Click on the up arrow on the pdf download box in lower left corner of screen
  • Choose Open

Firefox

Trying to open PDFs in Firefox could result in an error message that states "This PDF document contains forms. The filling of form fields is not supported."

To get the form to open in Adobe, you need to do the following:

  • Open Firefox
  • Click the Tools menu button
  • Click Options and select Applications
  • Find Portable Document Format (PDF) in the Content Type column
  • In the Action column, change it to Use Adobe Acrobat

Department of Human Services - Public Form(s)

SFNTitleSizeDateFillable
2 FFATA CERTIFICATION 322 kb 11/06/2012 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 841 kb 02/16/2021 Y
49 CHILD CARE ASSISTANCE PROGRAM DIRECT DEPOSIT BANKING INFO 1079 kb 02/10/2016 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 509 kb 08/25/2020 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
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
114 NURSING FACILITY REQUEST FOR STATE RETRO LEVEL OF CARE REVIE 382 kb 03/01/2018 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 478 kb 01/11/2021 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 598 kb 11/12/2019 Y
185 AWARE ND APPLICATION SUPPLEMENT 1370 kb 07/15/2020 Y
200 ASSET ASSESSMENT 1096 kb 09/08/2017 Y
209 CHILDCARE FACILITY FIRE DRILL RECORD 225 kb 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
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
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 FOSTER FAMILY CARE HOME CLAIM OF PROPERTY DAMAGE 392 kb 09/05/2019 Y
328 FAMILY FOSTER CARE HOME PROP DAMAGE VERIFICATION OF CLAIM 496 kb 09/05/2019 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
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 AUTHORIZATION TO TRANSFER BACKGROUND CHECK RESULTS 1288 kb 03/18/2021 Y
379 CORRECTION ORDER 1289 kb 02/02/2021 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
400 ANNUAL APPLICATION TO PROVIDE FAMILY FOSTER CARE 842 kb 10/15/2019 Y
404 MEDICAID WAIVER PERSON CENTERED PLAN OF CARE 1044 kb 07/14/2020 Y
405 APPLICATION FOR ASSISTANCE 4454 kb 01/02/2020 Y
408 KINSHIP NAVIGATION SERVICES APPLICATION 1117 kb 07/07/2021 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 964 kb 01/20/2021 Y
438 INCIDENT REPORT 1294 kb 12/15/2020 Y
443 NOTICE OF RIGHT TO CLAIM GOOD CAUSE 111 kb 08/21/2012 Y
445 FAMILY EVACUATION DISASTER PLAN 915 kb 04/15/2019 Y
446 REQUEST TO CLAIM GOOD CAUSE 88 kb 08/17/2012 Y
447 EXCEPTION FOR SUBMITTING ELECTRONIC CLAIMS 301 kb 05/22/2020 Y
451 ELIGIBILITY REPORT ON DISABILITY INCAPAS 620 kb 04/02/2015 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 914 kb 08/07/2018 Y
474 HCBS CASE CLOSURE/TRANSFER NOTICE/PROVIDER TERMINATION 418 kb 12/21/2018 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 476 kb 01/11/2021 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
501 HEALTH CARE COVERAGE REVIEW 624 kb 11/18/2016 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 1290 kb 07/13/2021 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 1151 kb 10/20/2020 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
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 878 kb 05/12/2021 Y
586 APPLICATION FOR MINOR IN POSSESSION (MIP) PROVIDER 938 kb 08/01/2019 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 12/17/2019 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
598 APPLICATIONS FOR CHILD CARE PROGRAMS 1616 kb 05/18/2020 Y
599 PRTF LICENSURE/REQUEST FOR CHANGE IN BED CAPACITY APPLICATIO 950 kb 01/06/2021 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 770 kb 04/21/2021 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 1611 kb 06/14/2018 Y
626 DETERMINE IF A CONTRACT REQUIRES BBA AND A QSO AGREEMENT 1247 kb 06/10/2020 Y
630 FOSTER CARE PLACEMENT NOTIFICATION 1020 kb 12/31/2019 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 TITLE IV-E TITLE XIX APPLICATION - FOSTER CARE 2318 kb 08/12/2019 Y
643 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 904 kb 07/17/2020 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 679 kb 08/16/2018 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 514 kb 01/29/2019 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 1359 kb 07/13/2021 Y
740 COMPANIONSHIP BILLING WORKSHEET 1290 kb 03/16/2021 Y
741 1915(I) ELIGIBILITY APPLICATION 1016 kb 07/28/2021 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
765 PAYPOINT PRE-AUTHORIZATION 166 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
800 FIRE SAFETY SELF DECLARATION FAMILY FOSTER CARE 1559 kb 09/27/2019 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 1298 kb 07/20/2021 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
834 APPLICATION FOR IN-HOME PROVIDER 1290 kb 04/20/2021 Y
836 FINGERPRINT IDENTITY VERIFICATION 905 kb 12/29/2020 Y
839 FOSTER CARE OVERPAYMENT NOTIFICATION 932 kb 04/01/2021 Y
841 CHILD CARE ASSISTANCE PROGRAM REVIEW 1492 kb 03/01/2021 Y
842 PLACEMENT ACKNOWLEDGEMENT FAMILY FOSTER HOMES 910 kb 09/17/2019 Y
843 FOSTER CARE PROVIDER FINANICAL REPORT 974 kb 03/08/2021 Y
844 RELATIVE WAIVER FAMILY FOSTER HOMES 935 kb 09/17/2019 Y
845 CHILD INFORMATION SHEET 505 kb 02/05/2020 Y
846 RELEASE OF INFORMATION-CHILD CARE FACILITY 174 kb 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 960 kb 09/27/2019 Y
851 ANNUAL LICENSING CHECKLIST FAMILY FOSTER HOME 961 kb 09/27/2019 Y
855 TITLE IV-E ADOPTION SUBSIDY ELIGIBILITY DETERMINATION 263 kb 03/03/2021 Y
859 SUBSTANCE ABUSE DISORDER VOUCHER PROGRAM APPLICATION 898 kb 06/09/2021 Y
863 LICENSING CHANGE CHECKLIST-FAMILY FOSTER HOMES 968 kb 03/11/2021 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 1208 kb 02/20/2013 Y
887 APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL) 1265 kb 09/16/2019 Y
888 PERSONAL AUTHORIZATION CRIM HISTORY INQ-CHILD ADVOCACY CTRS 1296 kb 07/14/2021 Y
890 AFFIDAVIT OF COMPLIANCE WITH LICENSING IN LIEU OF LICENSE FO 419 kb 09/05/2019 Y
892 INFORMED CHOICE REFERRAL FOR LONG-TERM CARE 967 kb 07/14/2021 Y
898 ANNUAL LICENSING APPLICATION QRTP 2292 kb 09/17/2019 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
925 RESPITE CARE REFERRAL 919 kb 12/23/2020 Y
928 AGREEMENT TO FURNISH SHELTER CARE 947 kb 07/16/2020 Y
929 AGREEMENT TO FURNISH RESPITE CARE 1513 kb 07/16/2020 Y
930 BACKGROUND INFORMATION FOR ADOPTION SERVICES 1.1 Mb 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
950 MEDICAID PAYMENT ALERT RCCF/BASIC CARE FACILITY 395 kb 09/08/2017 Y
958 HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED 2254 kb 06/16/2021 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
972 DECLARATION OF GOOD HEALTH 426 kb 09/16/2019 Y
973 EXTENDED PERSONAL CARE SERVICE PROVIDER PROCEDURE & TRAINING 336 kb 04/15/2019 Y
974 PHYSCIAL EXAM VERIFICATION FAMILY FOSTER HOME 925 kb 09/17/2019 Y
985 APPLICATION FOR ELIGIBILITY DETERMINATION 1063 kb 04/20/2021 Y
986 COMMUNITY CONNECT PROGRAM PROVIDER APPLICATION 1557 kb 06/28/2021 Y
991 MEDICAID PAYMENT ALERT 411 kb 03/04/2020 Y
992 QUALITY ASSURANCE (QA) CASE REVIEW ADOPTION CASE NARRATIVE 1708 kb 10/05/2020 Y
993 QA CASE REVIEW CHILD PROTECTIVE SERVICES CASE NARRATIVE 1715 kb 10/08/2020 Y
995 QA CASE REVIEW FOSTER CARE CASE NARRATIVE 1304 kb 10/19/2020 Y
996 QA CASE REVIEW IN-HOME CASE NARRATIVE 1864 kb 10/19/2020 Y
997 QA CASE REVIEW SUPERVISOR FOSTER CARE CASE QUESTIONNAIRE 1288 kb 10/05/2020 Y
998 QA CASE REVIEW SUPERVISOR IN-HOME CASE QUESTIONNAIRE 1287 kb 10/05/2020 Y
999 COMMUNITY-BASED BEHAVIORAL HEALTH PROG PARTICIPANT ELIGIBIL 974 kb 03/03/2021 Y
1000 VAPS EMERGENCY FUNDS APPLICATION 1723 kb 07/02/2021 Y
1001 VAPS EMERGENCY FUNDS PROVIDER BILLING 1291 kb 06/16/2021 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
1033 FOSTER CHILD TRAVEL AUTHORIZATION 1288 kb 04/29/2021 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 888 kb 12/21/2018 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
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
1177 REQUEST FOR GUARDIANSHIP ESTABLISHMENT FUNDS 1038 kb 05/04/2021 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
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 670 kb 08/25/2020 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
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
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 449 kb 10/06/2016 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
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/PROGRAM MANAGER ENVIRONMENTAL SCAN CHECKLIS 2071 kb 01/31/2020 Y
1560 DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY 909 kb 02/17/2021 Y
1595 SELF-DECLARATION PROVIDER REVIEW 1900 kb 05/14/2021 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 1574 kb 12/07/2020 Y
1604 REQUEST TO BE A QSP FOR FAMILY HOME CARE 1302 kb 12/20/2018 Y
1605 INDIVIDUAL REQUEST TO BE A QSP/AFC PROVIDER 984 kb 01/03/2019 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 06/29/2020 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
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
1694 SEARCH AND COPYING SERVICES RECORDS REQUEST 162 kb Y
1699 AUTHORIZATION TO PROVIDE SERVICES FOR SPED/EXSPED 329 kb 04/24/2019 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
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
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 924 kb 04/26/2021 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 DUI SEMINAR INSTRUCTOR CERTIFICATION/RECERT APPLICATION 913 kb 10/12/2017 Y
1907 EARLY CHILDHOOD INCLUSION SUPPORT GRANT APPLICATION 364 kb 05/26/2017 Y
1909 APPLICATION FOR HEALTH COVERAGE AND HELP PAYING COSTS 3856 kb 12/23/2019 Y
1910 WORK READINESS ASSESSMENT QUESTIONNAIRE 6164 kb 10/02/2013 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
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 MOBILE DEVICE REQUEST & AGREEMENT (DEPT & PERSONAL DEVICE 967 kb 06/15/2020 Y
1971 MOBILE DEVICE REQUEST & AGREEMENT - PERSONALLY OWNED DEVICE 948 kb 06/15/2020 Y
1972 ACCEPTABLE USE OF DEPARTMENT IT RESOURCES ACKNOWLEDGMENT 916 kb 06/15/2020 Y
1976 ASSISTIVE TECHNOLOGY AUTHORIZATION-AUTISM WAIVER 322 kb 11/30/2018 Y
1977 REQUEST FOR CONFIDENTIAL COMMUNICT BY ALTERNATE MEANS OR LOC 963 kb 02/01/2021 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 464 kb 08/16/2018 Y
60680 ELIGIBILITY AND LEVEL OF SUPPORT RECOMMENDATIONS (VABS) 340 kb 11/30/2018 Y