| SFN | Title | Size | Date | Fillable |
|
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
|
967 kb
|
07/17/2024
|
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
|
972 kb
|
10/07/2024
|
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
|
2172 kb
|
09/25/2024
|
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
|
1581 kb
|
07/17/2024
|
Y
|
|
201
|
RELATIVE FAMILY FACT FINDING
|
1726 kb
|
11/28/2022
|
Y
|
|
202
|
GROUP HOME & DRUG/ALCOHOL TREATMENT CTRS MONTHLY LISTING
|
941 kb
|
07/17/2024
|
Y
|
|
208
|
CARD PROBLEM REPORT
|
932 kb
|
07/19/2024
|
Y
|
|
217
|
SCSEP FAMILY SIZE THIRD PARTY ATTESTATION
|
953 kb
|
01/10/2023
|
Y
|
|
219
|
SCSEP SUPERVISOR'S VOLUNTARY IN-KIND WAGE FUNDING STATEMENT
|
919 kb
|
07/16/2024
|
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
|
946 kb
|
08/14/2024
|
Y
|
|
251
|
SCSEP CO-ENROLLMENT IN OTHER PROGRAM SERVICES
|
916 kb
|
07/16/2024
|
Y
|
|
252
|
CHAFEE EDUCATION AND TRAINING VOUCHER PROGRAM (ETV)
|
1522 kb
|
08/05/2024
|
Y
|
|
255
|
CHAFEE PROGRAM REQUEST FOR FINANCIAL ASSISTANCE
|
909 kb
|
01/07/2019
|
Y
|
|
269
|
MONTHLY DATA AND PAYMENT REPORT
|
930 kb
|
07/29/2024
|
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
|
916 kb
|
08/14/2024
|
Y
|
|
296
|
NON-EMERGENCY MEDICAL TRANSPORTATION TRIP TICKET
|
935 kb
|
08/20/2024
|
Y
|
|
298
|
PROTECTIVE SERVICE ALERT REPORT
|
949 kb
|
07/30/2024
|
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
|
|
302
|
AUTHORIZATION AND REQUEST FOR PAYMENT (DRUG/PHARMACY)
|
1497 kb
|
07/31/2024
|
Y
|
|
303
|
SNAP GROUP LIVING ARRANGEMENT & DRUG/ALCOHOL TRTM EXIT NOTIF
|
916 kb
|
07/31/2024
|
Y
|
|
306
|
CUSTODIAL TEAM MEETING DOCUMENTATION
|
1002 kb
|
09/09/2024
|
Y
|
|
308
|
MEDICAID & BASIC CARE ASSISTANCE PROGRAM AGREEMENT
|
940 kb
|
07/31/2024
|
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
|
922 kb
|
08/19/2024
|
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
|
947 kb
|
08/14/2024
|
Y
|
|
351
|
COMPANIONSHIP RURAL DIFFERENTIAL RATE AUTHORIZATION
|
906 kb
|
03/22/2022
|
Y
|
|
354
|
CHILD CARE WORKFORCE BENEFIT VERIFICATION
|
925 kb
|
09/03/2024
|
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
|
|
362
|
SNAP COMPUTATION SHEET
|
917 kb
|
07/24/2024
|
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
|
|
371
|
RESPITE CARE APPLICATION AND REFERRAL
|
941 kb
|
08/28/2024
|
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
|
1521 kb
|
11/19/2024
|
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
|
4564 kb
|
11/13/2024
|
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
|
|
411
|
AID TO BLIND/REMEDIAL (DENIAL NOTICE)
|
914 kb
|
08/29/2024
|
Y
|
|
412
|
AID TO BLIND/REMEDIAL (APPROVAL NOTICE)
|
925 kb
|
08/29/2024
|
Y
|
|
413
|
INDIVIDUAL INDIAN MONIES ACCOUNT
|
946 kb
|
02/13/2023
|
Y
|
|
414
|
SUBSIDIZED EMPLOYMENT AGREEMENT
|
909 kb
|
08/30/2024
|
Y
|
|
422
|
REQUEST FOR VERIFICATION OF DIVORCE
|
917 kb
|
09/12/2024
|
Y
|
|
423
|
KINSHIP PLACEMENT/AGREEMENT
|
954 kb
|
01/04/2024
|
Y
|
|
429
|
MEMO AGREEMENT TO ESTABLISH PROTECTIVE PAYMENTS
|
918 kb
|
09/23/2024
|
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
|
|
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
|
962 kb
|
09/19/2024
|
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
|
940 kb
|
09/27/2024
|
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
|
1021 kb
|
09/19/2024
|
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
|
08/12/2024
|
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
|
1197 kb
|
09/12/2024
|
Y
|
|
530
|
ELIGIBILITY AND BENEFIT WORKSHEET ENERGY
|
977 kb
|
10/16/2024
|
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
|
919 kb
|
10/03/2024
|
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
|
|
551
|
ND TRANSITION AND DIVERSION PILOT PROJECT REQUEST HOUSING
|
925 kb
|
08/20/2024
|
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
|
|
569
|
DEVELOPMENTAL DISABILITIES PROVIDER ADDENDUM
|
980 kb
|
08/29/2024
|
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
|
932 kb
|
10/11/2024
|
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
|
|
614
|
PHYSICIAN CERTIFICATION FOR HYSTERECTOMY AND STERILIZATION
|
328 kb
|
10/30/2019
|
Y
|
|
615
|
MEDICAID PROGRAM PROVIDER AGREEMENT
|
993 kb
|
11/19/2024
|
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
|
1319 kb
|
10/29/2024
|
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
|
11/12/2024
|
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)
|
931 kb
|
11/19/2024
|
Y
|
|
662
|
PERSONAL CARE SERVICES PLAN OF CARE & AUTHORIZATION IN A LIC
|
978 kb
|
07/08/2024
|
Y
|
|
664
|
ND TRANSITION & DIVERSION SERV PILOT PROJECT PROVIDER AGREE
|
954 kb
|
07/30/2024
|
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
|
|
674
|
COMPREHENSIVE CASE COORDINATION REFERRAL
|
959 kb
|
08/28/2024
|
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
|
|
691
|
AFFIDAVIT OF IDENTITY-FOR CHILDREN
|
273 kb
|
11/05/2024
|
Y
|
|
692
|
MFP NURSING ASSESSMENT BILLING WORKSHEET
|
925 kb
|
12/13/2022
|
Y
|
|
701
|
ANNUAL SNAP COMPLAINT LOG
|
983 kb
|
07/15/2024
|
Y
|
|
704
|
AUTHORIZATION TO PROVIDE (MFP) NURSING ASSESSMENT
|
904 kb
|
09/09/2022
|
Y
|
|
706
|
AFFIDAVIT OF EXPLANATION WHY CITIZENSHIP VERIFY NOT SUPPLIED
|
914 kb
|
11/05/2024
|
Y
|
|
707
|
CITIZENSHIP AFFIDAVIT
|
1474 kb
|
10/31/2024
|
Y
|
|
710
|
HEALTH TRACKS REFERRAL AND REQUEST FOR INFORMATION
|
296 kb
|
05/11/2020
|
Y
|
|
715
|
NORTH DAKOTA TDPP SERVICE AUTHORIZATION
|
937 kb
|
08/28/2024
|
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
|
|
736
|
CONTROLLED SUBSTANCE AGREEMENT
|
772 kb
|
04/26/2024
|
Y
|
|
739
|
AUTHORIZATION TO PROVIDE COMPANIONSHIP SERVICES
|
1371 kb
|
08/14/2024
|
Y
|
|
740
|
COMPANIONSHIP BILLING WORKSHEET
|
1300 kb
|
12/13/2023
|
Y
|
|
741
|
1915(I) ELIGIBILITY APPLICATION
|
1094 kb
|
11/06/2024
|
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
|
|
770
|
EBT CARD ISSUED BY MAIL
|
908 kb
|
10/22/2024
|
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
|
|
788
|
GROUP LIVING ARRANGEMENT AND DRUG/ALCOHOL TREATMENT CTR RPT'
|
920 kb
|
10/22/2024
|
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
|
913 kb
|
10/17/2024
|
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
|
|
813
|
REFERRAL TO OLDER BLIND PROGAM
|
913 kb
|
10/29/2024
|
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
|
929 kb
|
10/31/2024
|
Y
|
|
824
|
UNIVERSAL APPLICATION
|
1110 kb
|
10/10/2024
|
Y
|
|
826
|
CHILDREN'S TREATMENT SERVICES LOC DETERMINATION CSR
|
1044 kb
|
07/15/2024
|
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
|
912 kb
|
11/12/2024
|
Y
|
|
836
|
FINGERPRINT IDENTITY VERIFICATION
|
905 kb
|
09/07/2022
|
Y
|
|
839
|
FOSTER CARE OVERPAYMENT NOTIFICATION
|
949 kb
|
11/07/2024
|
Y
|
|
844
|
IDENTIFIED RELATIVE LICENSE - FAMILY FOSTER HOMES
|
964 kb
|
04/01/2024
|
Y
|
|
845
|
CHILD INFORMATION SHEET
|
931 kb
|
11/12/2024
|
Y
|
|
847
|
PARENTS STATEMENT ON HEALTH OF CHILD
|
940 kb
|
11/05/2024
|
Y
|
|
850
|
INITIAL LICENSING SPECIALIST CHECKLIST FAMILY FOSTER HOMES
|
974 kb
|
05/15/2024
|
Y
|
|
851
|
ANNUAL LICENSING SPECIALIST CHECKLIST FAMILY FOSTER HOMES
|
1022 kb
|
10/28/2024
|
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
|
949 kb
|
07/17/2024
|
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
|
1025 kb
|
08/19/2024
|
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)
|
1017 kb
|
11/15/2024
|
Y
|
|
887
|
APPLICATION FOR SUPERVISED INDEPENDENT LIVING (SIL)
|
981 kb
|
11/13/2024
|
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
|
|
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
|
09/04/2024
|
Y
|
|
922
|
HUMAN SERVICE ZONE REFERRAL FOR AASK PROGRAM
|
1035 kb
|
09/04/2024
|
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
|
973 kb
|
10/07/2024
|
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
|
928 kb
|
10/01/2024
|
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
|
2278 kb
|
09/30/2024
|
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
|
902 kb
|
09/03/2024
|
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
|
907 kb
|
09/19/2024
|
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
|
950 kb
|
09/03/2024
|
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
|
|
1082
|
18+ UNACCOMPANIED REFUGEE MINOR (URM) CONTINUED FOSTER CARE
|
927 kb
|
07/23/2024
|
Y
|
|
1083
|
UNACCOMPANIED REFUGEE MINOR (URM) PROGRAM NOTICE OF CHANGE
|
822 kb
|
08/12/2024
|
Y
|
|
1084
|
NOTICE TO NDHHS DETERMINATION OF SPECIAL NEEDS
|
932 kb
|
09/23/2024
|
Y
|
|
1085
|
URM HIGHER LEVEL OF CARE FUNDING REQUEST
|
929 kb
|
09/09/2024
|
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
|
|
1195
|
ND VR COMMUNITY REHABILITATION PROVIDER APPLICATION
|
1013 kb
|
08/23/2024
|
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
|
918 kb
|
10/01/2024
|
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
|
08/14/2024
|
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
|
2144 kb
|
09/18/2024
|
Y
|
|
1560
|
DEVELOPMENTAL DISABILITIES TERMINATION SUMMARY
|
918 kb
|
02/15/2023
|
Y
|
|
1573
|
DEVELOPMENTAL DISABILITIES REFERRAL
|
937 kb
|
04/19/2023
|
Y
|
|
1584
|
TREATMENT PROVIDER WORK RESTRICTIONS EVALUATION
|
937 kb
|
11/20/2024
|
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
|
09/12/2024
|
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
|
922 kb
|
10/25/2024
|
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
|
1004 kb
|
11/07/2024
|
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
|
1821 kb
|
10/16/2024
|
Y
|
|
1839
|
OUT OF SEQUENCE FOR MAJOR LIFE CHANGING EVENT ASSESSMENT REQ
|
1318 kb
|
10/16/2024
|
Y
|
|
1842
|
SCSEP PROGRAM APPLICATION
|
1062 kb
|
05/01/2024
|
Y
|
|
1843
|
CLIENT REGISTRATION (CENTER ADMISSION)
|
1078 kb
|
08/14/2024
|
Y
|
|
1853
|
INDIVIDUAL EMPLOYMENT SUPPORTS OUTLIER REQUEST
|
931 kb
|
10/16/2024
|
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
|
2268 kb
|
08/05/2024
|
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
|
08/13/2024
|
Y
|
|
1993
|
FACILITY IMPROVEMENT GRANT FINAL REPORT
|
913 kb
|
08/23/2024
|
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 PRACTITIONERS'S WORKSHEET
|
877 kb
|
07/19/2024
|
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
|
|
62098
|
ND RENT HELP APPEAL
|
948 kb
|
11/07/2024
|
Y
|
|
62164
|
LIHEAP CLAIM
|
1481 kb
|
11/07/2024
|
Y
|
|
62192
|
HEALTH AND WELFARE/CHAIN OF CUSTODY
|
945 kb
|
07/20/2022
|
Y
|
|
62230
|
VACCINATION ASSISTANCE REQUEST
|
173 kb
|
09/28/2022
|
Y
|
