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... Ownership and Control Interest of an Entity (DHS-5259) Provider Entity Sale or Transfer Addendum (DHS-5550) ... Ownership and Control Interest of an Entity (DHS-5259) Provider Entity Sale or Transfer Addendum (DHS-5550) ...
Description: This page lists all Provider Eligibility and Compliance (PEC) enrollment forms that accept electronic signatures
Date:
August
12, 2025
... Ownership
and Control Interest of an Entity (DHS-
5259) (PDF)
Fitness Test
•
Fitness tests may be conducted ... when you
submit the
Disclosure of Ownership (DHS-5259) (PDF)
.
•
Owners
are individuals with direct or indirect ...
Description: SFS Provider Screening PowerPoint
Date:
August
25, 2025
... County
Medicaid
Other
165988
144
86045259.73
597536.5259
518.3824116
2021
Clearwater County
Medicaid
All
43785
... 12
109.12
2022
Todd County
MNCare
All
5259
21
1920605.27
91457.39381
365.2035121
2022
...
Date:
July
18, 2025
... the Disclosure of Ownership and Control Interest (DHS-5259) . back to top
Description: The following questions and answers provide further details about the Home and Community-Based Services (HCBS) revalidation process.
Date:
October
14, 2024
... Ownership and Control Interest of an Entity (DHS-5259) (PDF) during enrollment. If a QP is an ...
Description: The Minnesota Department of Human Services (DHS) is in the process of transitioning from personal care assistance (PCA) to Community First Services and Supports (CFSS). During this transition time, Steps for Success training covers information from both programs. To learn more about CFSS, visit Community First Services and Supports.
Date:
April
21, 2025
... Ownership and Control Interest of an Entity (DHS-5259) (PDF) form, or any other employees, are on ... PDF) • Disclosure of Ownership and Control Interest (DHS-5259) (PDF) • Assurance Statement for EIDBI Provider Agencies (DHS- ...
... Ownership and Control Interest of an Entity (DHS-5259) or any other employees are on the MHCP ... 4138) • Disclosure of Ownership and Control Interest (DHS-5259) • Waiver and Alternative Care (AC) Programs Service Request ...
... Ownership and Control Interest of an Entity (DHS-5259) (PDF) or any other employees are not on ... managers identified on the Disclosure of Ownership (DHS-5259). Follow the instructions in the Request for Licensing ...
... Ownership and Control Interest of an Entity (DHS-5259) (PDF) on file with MHCP and meets requirements ...
... Ownership and Control Interest of an Entity (DHS-5259) (PDF) • EFT Vendor Number Notification (DHS-3725) (PDF) ...