Minnesota Department of Human Services accepts electronic signatures on these Minnesota Health Care Programs (MHCP) forms
DHS accepts electronic signatures and initials on the following MHCP enrollment forms:
Agreement and agreement addendums
- PCPO Provider Agreement Addendum (DHS-4022A)
- PCA Choice Provider Agreement (DHS-4022B)
- Qualified Professional (QP) Acknowledgement (DHS-4022C)
- Electronic Remittance Advice (RA) Request (DHS-4087)
- Provider Agreement (DHS-4138)
- ICF/DD Training and Habilitation Agreement (DHS-4224)
- Individual Support Worker (CDCS, CSG, PCA, CFSS) Provider Agreement (DHS-4611)
- Individual Non-Pay-To Provider Agreement (DHS-4611A)
- Volunteer Dentists Provider Agreement (DHS-4611B)
- Child and Teen Checkups (C&TC) Provider Agreement Addendum (DHS-4646)
- Sage and Screen Our Circle Screening Programs Medical Assistance (MA) Presumptive Eligibility Agreement (DHS-4786)
- Financial Management Services (FMS) – Provider Agreement Addendum for CFSS, CDCS and CSG Services (DHS-7002)
Assurance statements
- Behavioral Health Fund (BHF) Provider Assurance Statement (DHS-3491)
- Advanced Diagnostic Imaging Assurance Statement (DHS-3872)
- Supported Employment Service - Moving Home Minnesota - Provider Assurance Statement (DHS-3873)
- Moving Home Minnesota (MHM) - Transition Planning, Transition Coordination and Demonstration Case Management Provider Assurance Statement (DHS-3879)
- Hospital Presumptive Eligibility Provider Assurance Statement (DHS-3887)
- Hospital In-Reach Service Coordination (IRSC) Provider Assurance Statement (DHS-3898)
- Limited General Dentist Assurance Statement (DHS-3932)
- Notification of Certified Provider Locations (DHS-4773)
- Limiting MHCP Caseload (Rule 101) Provider Assurance Statement (DHS-5078)
- Limiting MHCP Caseload (Rule 101) Provider Assurance Statement (DHS-5078A)
- Community Health Worker (CHW) Provider Assurance Statement (DHS-5308)
- Community Health Clinic Provider Assurance Statement (DHS-5732)
- Community Mental Health Center Assurance Statement (DHS-5748)
- Tribal Provider Assurance Statement for Assessments for Personal Care Assistance (PCA) or Community First Services and Supports (CFSS) (DHS-5857)
- PCA Agency Provider Assurance Statement (DHS-6005)
- Collaborative Practice Dental Hygienist Assurance Statement (DHS-6025)
- Certified Mental Health Rehabilitation Professional Assurance Statement (DHS-6095)
- Adult Day Services Provider Assurance Statement (DHS-6189AA)
- Alternative Care (AC) Nutrition Services Provider Assurance Statement (DHS-6189B)
- Adult Companion Services or Individualized Home Supports without Training Provider Assurance Statement (DHS-6189C)
- Personal Emergency Response System Provider Assurance Statement (DHS-6189CC)
- Assistive Technology Provider Assurance Statement (DHS-6189D)
- Chore Services Provider Assurance Statement (DHS-6189F)
- Environmental Accessibility Provider Assurance Statement (DHS-6189G)
- Family Caregiver Services Provider Assurance Statement (DHS-6189H)
- Family Training and Counseling Provider Assurance Statement (DHS-6189I)
- Home Delivered Meals Provider Assurance Statement (DHS-6189J)
- Homemaker Provider Assurance Statement (DHS-6189K)
- Independent Living Skills Therapy Provider Assurance Statement (DHS-6189M)
- Specialized Equipment and Supplies Provider Assurance Statement (DHS-6189T)
- Transitional Services Provider Assurance Statement (DHS-6189W)
- Customized Living Provider Assurance Statement (DHS-6189X)
- Waiver Transportation Provider Assurance Statement (DHS-6189Y)
- Provider Not Required to Receive a 245D Program License – Provider Assurance Statement (DHS-6189Z)
- Qualified Mental Health Professional Clinical Supervision Assurance Statement (DHS-6330)
- Residential or Inpatient Behavioral Health Fund (BHF) Service Request (DHS-6381)
- Outpatient Behavioral Health Fund (BHF) Service Request (DHS-6382)
- Telemedicine Provider Assurance Statement (DHS-6806)
- Overnight Assistance Provider Assurance Statement (DHS-6808)
- Home Care Nurse – Individual LPN or RN Provider Assurance Statement (DHS-7099)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Comprehensive Multi-Disciplinary Evaluation (CMDE) Provider Assurance Statement (DHS-7120A)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Provider Agency Assurance Statement (DHS-7120B)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Qualified Supervising Professionals (QSP) Assurance Statement (DHS-7120C)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Level I Provider Assurance Statement (DHS-7120D)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Level II Provider Assurance Statement (DHS-7120E)
- Early Intensive Developmental and Behavioral Intervention (EIDBI) Level III Provider Assurance Statement (DHS-7120F)
- Immunization Delivery for Dentists Provider Assurance Statement (DHS-7121)
- Pharmacy Retrospective Billing Assurance Statement (DHS-7227)
- 1115 Substance Use Disorder (SUD) System Reform Demonstration Project Provider Assurance Statement (DHS-7323)
- Officer-Involved Community-Based Care Coordination Assurance Statement (DHS-7340)
- Home and Community-Based Settings Provider Assurance Statement (DHS-7618)
- Critical Access Mental Health Provider Assurance Statement (DHS-7689)
- Substance Use Disorder (SUD) Provider Assurance Statement – Professionals (DHS-7754)
- Positive Supports Provider Assurance Statement (DHS-7807)
- Substance Use Disorder (SUD) Provider Assurance Statement - Counties and Tribes (DHS-7820)
- Crisis Respite Specialized Staff Provider Assurance Statement (DHS-7886)
- Housing Transition and Housing Sustaining Provider Assurance Statement (DHS-7967)
- Housing Consultation Provider Assurance Statement (DHS-7968)
- Waiver Services Remote Support Provider Assurance Statement (DHS-8059)
- Customized Living Service Provider – Exempt from Assisted Living Facility Licensure – Assurance Statement (DHS-8116)
- Respite Providers with a 245D or 144A License Providing Services in an Unlicensed Setting – Assurance Statement (DHS-8122)
- Community First Services and Supports (CFSS) Assurance Statement for Consultation Services Lead Employee (DHS-8141)
Provider enrollment applications
- Home and Community Based Services (HCBS) – Provider Enrollment Application (DHS-4015)
- Individual Provider Enrollment Application (DHS-4016)
- Organization – Provider Enrollment Application (DHS-4016A)
- Personal Care Provider Organization or Personal Care Assistant Choice Provider Enrollment Application (DHS-4022)
- Billing Intermediaries, Clearinghouses and EDI Trading Partners Provider Enrollment Application (DHS-4049)
- Individual Personal Care Assistant (PCA) Enrollment Application (DHS-4469)
- Individual Direct Support Worker Enrollment Application (Consumer Directed Community Supports [CDCS] and Consumer Support Grant [CSG]) (DHS-4469A)
- Health Care Case Coordinator – Provider Enrollment Application (DHS-4474)
- Third Party Administrator Enrollment Application (DHS-5859)
- Direct Care and Treatment Organization – Provider Enrollment Application (DHS-6368)
- Lead Agency Assurance Statement: HCBS Provider Review and Approval (DHS-6383)
- Housing Stabilization Services – Provider Enrollment Application (DHS-8018)
Ownership and other disclosing forms
- MHCP Individual Provider Profile Change (DHS-3535)
- MHCP Organization Provider Profile Change (DHS-3535A)
- EFT Supplier ID Notification (DHS-3725)
- Hardship Exemption Request (DHS-3901)
- Alternative Payment Methodology Election for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) (DHS-3903)
- Assignment of Payment for Day Training and Habilitation Services (DHS-4223)
- Disclosure of Ownership and Control Interest of an Entity (DHS-5259)
- Provider Entity Sale or Transfer Addendum (DHS-5550)
- Individual DSW Information Change Request (DHS-5716)
- Third Party Administrator Managed Care Organization (MCO) Setup (DHS-5858)
- Home and Community-Based Services (HCBS) Programs Service Request (DHS-6638)
- Designation of Billing Person for Home and Community-Based Services Waiver or Alternative Care (DHS-6855)