Page 1 of 95 MINNESOTA GOVERNMENT DATA PRACTICES ACT · Page 1 of 95 This document is a public record pursuant to Minnesota Statute 13.05 2/1/2018 70001-1 Completed fee cover sheet

Page 1 of 95

This document is a public record pursuant to Minnesota Statute 13.05 2/1/2018

70001-1 Completed fee cover sheet Private M.S. 13.46, subd. 2 Catie Lee

70000-6 Administrative appeal Private M.S. 13.46, subd. 2 Catie Lee

70000-8 Contracted vendor qrtrly report form "X" Private M.S. 13.46, subd. 2 Catie Lee

70000-9 Client summary annual report form "Y" Private M.S. 13.46, subd. 2 Catie Lee

Notice of social services action Private M.S. 13.46, subd. 2 Catie Lee

Calculation of the parental fee Private M.S. 13.46, subd. 2 Catie Lee

70000-15 Maltreatment summary for record destruction from private information

Private M.S. 13.46, subd. 2 Catie Lee

Notice of privacy practices and Tennessen Warning Private M.S. 13.46, subd. 2 Catie Lee

Noticie of privacy practices and Tenneseen Warning - Spanish Private M.S. 13.46, subd. 2 Catie Lee

70000-18b Acknowledgement of receipt of privacy practices - Hmong Private M.S. 13.46, subd. 2 Catie Lee

70000-20 Completed information disclosure request for private, confidential, non-public, or protected non-public data

Private M.S. 13.46. subd. 2 Catie Lee

70000-21 Completed electronic data consent form Private M.S. 13.46, subd. 2 Catie Lee

70000-24 CP/VA background check - completed - cover letter Private M.S. 13.46, subd. 2 Catie Lee

Name of Form, Record, File, System, or Process

Description(Purpose, what it collects, in terms understandable by general public) Classification

Citation for Classification

(Statute, Law, or Rule)

Designee(Name, Title)

MINNESOTA GOVERNMENT DATA PRACTICES ACT

2016 INVENTORY OF NOT PUBLIC DATA ON INDIVIDUALS

Swift CountyResponsible Authority - Catie Lee

Community Social Services Director

Social Services

Page 2 of 95











Social Services

70000-26 Completed request - gas and food (vendor) cards Private M.S. 13.46, subd. 2 Catie Lee

Completed consent for release and exchange of information Private M.S. 13.46, subd. 2 Catie Lee

Request for Prairie 5 Rides Private M.S. 13.46, subd. 2 Catie Lee

Completed death and serious injury reporting form Private M.S. 13.46, subd. 2 Catie Lee

70000-33 Completed additional information needed - address book request form


70000-34 Client copy work fees cover letter Private M.S. 13.46, subd. 2 Catie Lee

70000-35 Completed car seat recipient release form Private M.S. 13.46, subd. 2 Catie Lee

70000-37 Lead agency case mgr wrkr communication form Private M.S. 13.46, subd. 2 Catie Lee

Informed consent to release info (Rel. #3) Private M.S. 13.46, subd. 2 Catie Lee

70000-41 Completed CDCS - CCT - DD Checklist Private M.S. 13.46, subd. 2 Catie Lee

70000-44 Completed CDCS - notice - authorization - alternative billing Private M.S. 13.46, subd. 2 Catie Lee

70000-47 CDCS - verify - prescribed diet and eval. of special diet Private M.S. 13.46, subd. 2 Catie Lee

70000-48 CDCS - budgeting cap letter Private M.S. 13.46. subd. 2 Catie Lee

Page 3 of 95











Social Services

70000-49 Completed parent - staff weekly schedule and job description Private M.S. 13.46, subd. 2 Catie Lee

70000-50 CDCS - corrective action notice Private M.S. 13.46, subd. 2 Catie Lee

70000-51 CDCS - plan review/approval - fillable and written Private M.S. 13.46, subd. 2 Catie Lee

70000-53 CDCS – revision request form – fillable & written Private M.S. 13.46, subd. 2 Catie Lee

70000-55 CDCS – participation agreement Private M.S. 13.46, subd. 2 Catie Lee

70000-56 CDCS – plan review Private M.S. 13.46, subd. 2 Catie Lee

70000-59 CDCS – community support plan and budget Private M.S. 13.46, subd. 2 Catie Lee

70000-62 CDCS – community support plan – Rule 185 compliant - DD Private M.S. 13.46, subd. 2 Catie Lee

70000-NA ESS gas authorization – emergency SS Private M.S. 13.46, subd. 2 Catie Lee

70000-NA Housing search log Private M.S. 13.46. subd. 2 Catie Lee

70000-NA Out of co/agency CP/VA background checks log Private M.S. 13.46, subd. 2 Catie Lee

71040-2 Referral of suspected child abuse or neglect Private M.S. 13.46, subd. 2 Catie Lee

Intake - social service referral Private M.S. 13.46, subd. 2 Catie Lee

Page 4 of 95











Social Services

Notification to school to interview child Private M.S. 13.46, subd. 2 Catie Lee

71040-5 Request for child protection day care Private M.S. 13.46. subd. 2 Catie Lee

Completed Child Protection For Your Information (Tennessen) Private M.S. 13.46, subd. 2 Catie Lee

Notice of 72-hour peace officer health and welfare hold Private M.S. 13.46, subd. 2 Catie Lee

71040-16 Completed intake log - intake/assessment Private M.S. 13.46, subd. 2 Catie Lee

71040-29 Am. red cross - crisis response report Private M.S. 13.46, subd. 2 Catie Lee

71040-31 Citizen review panel - per diem form - SS# Private M.S. 13.46, subd. 2 Catie Lee

71040-47 Authorization for medical exam reimbursement worksheet Private M.S. 13.46, subd. 2 Catie Lee

71040-58 Alternative response family assessment worksheet Private M.S. 13.46, subd. 2 Catie Lee

71040-60 36-hour detention request form Private M.S. 13.46, subd. 2 Catie Lee

Local child mortality/near fatality review meeting Private M.S. 13.46, subd. 2 Catie Lee

Notice of Determination Letter (NOD) - Alleged Offender - NO Determ or CPS Needed


Notice of Determination Letter (NOD) - Alleged Offender - Abuse/Neglect OCCURRED-CPS NOT needed


Page 5 of 95











Social Services

Notice of Determination Letter (NOD) - Alleged Offender - Abuse/Neglect OCCURRED-CPS NEEDED


Notice of Determination Letter (NOD) - Alleged Offender - NO Determ - CPS NEEDED


Notice of Determination Letter (NOD) - Offending Parent - NO Determination - CPS NEEDED


Notice of Determination Letter (NOD) - Offending Parent - NO Determination - CPS NOT Needed


Notice of Determination Letter (NOD) - Offending Parent - Abuse/Neglect OCCURRED - CPS NEEDED


Notice of Determination Letter (NOD) - Non-Offending Parent - Abuse/Neglect OCCURRED - CPS NOTE Needed


Supervised Vistitation Notes Private M.S. 13.46. subd. 2 Catie Lee

71600-10 Eco map (understanding the family in its world) Private M.S. 13.46, subd. 2 Catie Lee

71600-11 Minor Parent Assessment Private M.S. 13.46, subd. 2 Catie Lee

Stepparent adoption study and information Private M.S. 13.46, subd. 2 Catie Lee

71600-19 Personal needs allowance form SSI benefits monthly billing Private M.S. 13.46, subd. 2 Catie Lee

Foster care for youth 18-21 monthly billing Private M.S. 13.46, subd. 2 Catie Lee

Page 6 of 95











Social Services

71600-NA Cklst for youth 16+ in out-of-home care Private M.S. 13.46, subd. 2 Catie Lee

71930-2 Notification of placement authority Private M.S. 13.46, subd. 2 Catie Lee

71930-3 Face sheet - Admin. Rvw. - child in out-of-home placement Private M.S. 13.46. subd. 2 Catie Lee

71930-4 Home detention contract Private M.S. 13.46, subd. 2 Catie Lee

71930-5 Invite - administrative review placement letter - CP template Private M.S. 13.46, subd. 2 Catie Lee

Voluntary placement agreement Private M.S. 13.46, subd. 2 Catie Lee

71930-14 Intake team referral Private M.S. 13.46, subd. 2 Catie Lee

71930-15 Agreement - routine and typical medical care (child under care of WCCS)


71930-17 Request for transportation Private M.S. 13.46, subd. 2 Catie Lee

71930-22 Clothing request Private M.S. 13.46, subd. 2 Catie Lee

71930-26 Community work service assignment Private M.S. 13.46, subd. 2 Catie Lee

71930-30 Permanency team review Private M.S. 13.46, subd. 2 Catie Lee

Child Protection Face Sheet Private M.S. 13.46, subd. 2 Catie Lee

Page 7 of 95











Social Services

71930-40 Permanency petition worksheet Private M.S. 13.46. subd. 2 Catie Lee

71930-46 Teen parent evaluation Private M.S. 13.46, subd. 2 Catie Lee

71930-47 Decision making - plans for the baby Private M.S. 13.46, subd. 2 Catie Lee

RCA annual affidavit Private M.S. 13.46, subd. 2 Catie Lee

RCA payment worksheet Private M.S. 13.46, subd. 2 Catie Lee

71930-59 Decision making worksheet - father Private M.S. 13.46. subd. 2 Catie Lee

71930-60 Decision making worksheet - couple Private M.S. 13.46, subd. 2 Catie Lee

71930-62 Case consultation data sharing agreement Private M.S. 13.46, subd. 2 Catie Lee

71930-63 Family safety plan (alternative response) Private M.S. 13.46, subd. 2 Catie Lee

Safety plan Private M.S. 13.46, subd. 2 Catie Lee

71930-65 Housekeeping checklist Private M.S. 13.46, subd. 2 Catie Lee

71930-66 Financial statement (proposed) Private M.S. 13.46, subd. 2 Catie Lee

71930-67 Brief in-home services Private M.S. 13.46, subd. 2 Catie Lee

71930-70 MH screening results letter (child) Private M.S. 13.46, subd. 2 Catie Lee

71930-72 MH screening notice Private M.S. 13.46. subd. 2 Catie Lee

Page 8 of 95











Social Services

71930-75 Request - family service worker Private M.S. 13.46, subd. 2 Catie Lee

71930-76 Full disclosure statement - conc. plng. - parents of kids in FC Private M.S. 13.46, subd. 2 Catie Lee

71930-78 Case transition meeting form Private M.S. 13.46, subd. 2 Catie Lee

71930-82 Client/parent safety plan Private M.S. 13.46, subd. 2 Catie Lee

71930-83-EN Completed data privacy notification - ed neglect Private M.S. 13.46. subd. 2 Catie Lee

71930-83-T Complete data privacy notification (truancy) Private M.S. 13.46, subd. 2 Catie Lee

71930-85 Ed neglect - diversion and school attendance contract Private M.S. 13.46, subd. 2 Catie Lee

71930-86 Ed neglect diversion referral Private M.S. 13.46, subd. 2 Catie Lee

71930-87 Ed neglect letter (parent) template Private M.S. 13.46, subd. 2 Catie Lee

71930-88 Ed neglect tracking sheet Private M.S. 13.46, subd. 2 Catie Lee

71930-93 Truancy - diversion and school attendance contract Private M.S. 13.46, subd. 2 Catie Lee

Truancy Meeting Letter Private M.S. 13.46, subd. 2 Catie Lee

Truancy Meeting Summary Private M.S. 13.46, subd. 2 Catie Lee

71930-96 Truancy - year end letter #1 Private M.S. 13.46, subd. 2 Catie Lee

Page 9 of 95











Social Services

71930-97 Truancy - year end letter #2 Private M.S. 13.46. subd. 2 Catie Lee

71930-98 Truancy - year end letter #3 Private M.S. 13.46, subd. 2 Catie Lee

71930-99 12-15 year olds truancy diversion referral tracking sheet Private M.S. 13.46, subd. 2 Catie Lee

71930-100 16-17 year olds referrals from court tracking sheet Private M.S. 13.46, subd. 2 Catie Lee

71930-101 Open cases referral out tracking sheet Private M.S. 13.46, subd. 2 Catie Lee

71930-102 Excused medial absences Private M.S. 13.46. subd. 2 Catie Lee

71930-106 Efforts to locate non-custodial parent Private M.S. 13.46, subd. 2 Catie Lee

71930-109 Year-end letter 4 (18 year olds - truancy) Private M.S. 13.46, subd. 2 Catie Lee

71930-110 Fax cover sheet - childs court report Private M.S. 13.46, subd. 2 Catie Lee

71930-111 Child mortality log Private M.S. 13.46, subd. 2 Catie Lee

71930-112 Client's list of psychotropic medications Private M.S. 13.46, subd. 2 Catie Lee

71930-NA AAA verification card Private M.S. 13.46, subd. 2 Catie Lee

child fatality report Private M.S. 13.46, subd. 2 Catie Lee

71930-NA Attachment B - report of records search Private M.S. 13.46, subd. 2 Catie Lee

Page 10 of 95











Social Services

71930-NA Attachment C-1 - child death attributed to maltreatment Private M.S. 13.46, subd. 2 Catie Lee

71930-NA Attachment C-2 - CP svs record review Private M.S. 13.46, subd. 2 Catie Lee

71930-NA Attachment C-3 - record rvw - child in subst care Private M.S. 13.46, subd. 2 Catie Lee

71930-NA Attachment C-3 - record rvw - family & group day care Private M.S. 13.46, subd. 2 Catie Lee

Concurrent planning full disclosure statement Private M.S. 13.46, subd. 2 Catie Lee

Permanency relative search letter - GEN Private M.S. 13.46, subd. 2 Catie Lee

Permanency relative response letter - GEN Private M.S. 13.46. subd. 2 Catie Lee

71930-NA Initial relative search letter - GEN Private M.S. 13.46, subd. 2 Catie Lee

71930-NA Initiative relative search response letter - GEN Private M.S. 13.46, subd. 2 Catie Lee

Adoption reference option letter - questions Private M.S. 13.46, subd. 2 Catie Lee

71960-9 Completed information form Private M.S. 13.46, subd. 2 Catie Lee

Child foster home licensing review Private M.S. 13.46. subd. 2 Catie Lee

Notice to medical vendors Private M.S. 13.46, subd. 2 Catie Lee

FC - letter of reference Private M.S. 13.46, subd. 2 Catie Lee

71980-6 Placement check-in form Private M.S. 13.46, subd. 2 Catie Lee

Page 11 of 95











Social Services

71980-7 Visitation log for new foster parents Private M.S. 13.46, subd. 2 Catie Lee

FC - applicant information Private M.S. 13.46, subd. 2 Catie Lee

Record of corp. AFC staff training - use of med. Equipment Private M.S. 13.46, subd. 2 Catie Lee

Corp. foster care applicant background study Private M.S. 13.46, subd. 2 Catie Lee

Adult and child family FC and adptn. - background "check" study - Adam Walsh

Private M.S. 13.46, subd. 2 Catie lee

Corp. foster care employee background study Private M.S. 13.46, subd. 2 Catie Lee

71980-11d Corp. foster care employee background study - DS v Private M.S. 13.46. subd. 2 Catie Lee

Evaluation of the agency by the foster family Private M.S. 13.46, subd. 2 Catie Lee

71980-12a Evaluation of the agency by the adult foster family Private M.S. 13.46, subd. 2 Catie Lee

FC - questionnaire Private M.S. 13.46, subd. 2 Catie Lee

Evaluation of services of FC provider Private M.S. 13.46, subd. 2 Catie Lee

Foster Care Provider Health Care record Private M.S. 13.46. subd. 2 Catie Lee

71980-17 FC - monthly activity report Private M.S. 13.46, subd. 2 Catie Lee

Page 12 of 95











Social Services

Foster home relicensing Private M.S. 13.46, subd. 2 Catie Lee

71980-19 Foster home in-use Private M.S. 13.46, subd. 2 Catie Lee

School/activity permission Private M.S. 13.46, subd. 2 Catie Lee

71980-25 FC - autobiography Private M.S. 13.46, subd. 2 Catie Lee

71980-27 Resident monthly cash record Private M.S. 13.46, subd. 2 Catie Lee

71980-28 Adult foster home program Private M.S. 13.46, subd. 2 Catie Lee

71980-29 Family foster care training and skills form Private M.S. 13.46, subd. 2 Catie Lee

71980-30 FC - monthly billing Private M.S. 13.46, subd. 2 Catie Lee

71980-30a DD FC monthly billing Private M.S. 13.46. subd. 2 Catie Lee

71980-32 Corp. notification to lic. worker of FC placement/discharge Private M.S. 13.46, subd. 2 Catie Lee

FC - out-of-state travel consent Private M.S. 13.46, subd. 2 Catie Lee

71980-36 AFC - resident information Private M.S. 13.46, subd. 2 Catie Lee

71980-37 Individual resident placement agreement Private M.S. 13.46, subd. 2 Catie Lee

71980-39 School contact record Private M.S. 13.46. subd. 2 Catie Lee

Page 13 of 95











Social Services

71980-40 Ref. AFC non-consolidated stds. licensure Private M.S. 13.46, subd. 2 Catie Lee

CFC - initial licensing packet letter template Private M.S. 13.46, subd. 2 Catie Lee

71980-48 AFC - placement request Private M.S. 13.46, subd. 2 Catie Lee

71980-49 AFC - history and physical exam form Private M.S. 13.46, subd. 2 Catie Lee

CFC - MAPCY Assessment Private M.S. 13.46, subd. 2 Catie Lee

Permission for AFC provider to administer medications Private M.S. 13.46, subd. 2 Catie Lee

AFC - program abuse prevention plan Private M.S. 13.46, subd. 2 Catie Lee

71980-57 Consent to share a bedroom with a particular person Private M.S. 13.46, subd. 2 Catie Lee

71980-61 Completed client confidentiality Private M.S. 13.46, subd. 2 Catie Lee

CFC - incident report Private M.S. 13.46. subd. 2 Catie Lee

AFC - incident report Private M.S. 13.46, subd. 2 Catie Lee

AFC - relicensing - corporation Private M.S. 13.46, subd. 2 Catie Lee

71980-69a AFC program employee reporting form Private M.S. 13.46, subd. 2 Catie Lee

71980-69c AFC employee annual report Private M.S. 13.46, subd. 2 Catie Lee

71980-73 Difficulty of care rating sheer Private M.S. 13.46. subd. 2 Catie Lee

Page 14 of 95











Social Services

71980-76 Foster parent evaluation of child placement Private M.S. 13.46, subd. 2 Catie Lee

71980-80 Non-waivered corp. alternate year review Private M.S. 13.46, subd. 2 Catie Lee

71980-83 Specialized svs. home roster and out-of-county shelter Private M.S. 13.46, subd. 2 Catie Lee

71980-90 Request for foster home licensing study Private M.S. 13.46, subd. 2 Catie Lee

71980-96 [P] AFC - medical/dental visit/order form (provider vsn.) Private M.S. 13.46, subd. 2 Catie Lee

Clothing inventory Private M.S. 13.46, subd. 2 Catie Lee

Service Arrangement for out-of-home placement Private M.S. 13.46, subd. 2 Catie Lee

Completed complaint-grievance procedure Private M.S. 13.46, subd. 2 Catie Lee

CFC - health status of applicants/household member Private M.S. 13.46, subd. 2 Catie Lee

71980-106 Complaint/grievance written form Private M.S. 13.46, subd. 2 Catie Lee

71980-109 Corp. alternate year review Private M.S. 13.46, subd. 2 Catie Lee

71980-110 Initial corp. lic. checklist Private M.S. 13.46, subd. 2 Catie Lee

71980-114 Family contact record Private M.S. 13.46, subd. 2 Catie Lee

71980-115 Placement memories Private M.S. 13.46, subd. 2 Catie Lee

Page 15 of 95











Social Services

AFC - relicensing checklist Private M.S. 13.46, subd. 2 Catie Lee

71980-119 Personal health and medical record form Private M.S. 13.46, subd. 2 Catie Lee

71980-122 FC - extension request Private M.S. 13.46, subd. 2 Catie Lee

CFC - record of training Private M.S. 13.46, subd. 2 Catie Lee

71980-126 Adult placement request for dispositions Private M.S. 13.46, subd. 2 Catie Lee

71980-127 FC damage request claim form Private M.S. 13.46, subd. 2 Catie Lee

71980-128 Child placement request for dispositions Private M.S. 13.46, subd. 2 Catie Lee

Purchase of service agreement Private M.S. 13.46, subd. 2 Catie Lee

71980-131 AFC - Home death report Private M.S. 13.46, subd. 2 Catie Lee

71980-132 AFC - Family background tracking form (lic.) Private M.S. 13.46, subd. 2 Catie Lee

71980-138 Medical appointments Private M.S. 13.46, subd. 2 Catie Lee

71980-148 Non-consolidated corp. relicensing letter template Private M.S. 13.46, subd. 2 Catie Lee

71980-149 Consolidated corp. relicensing letter template Private M.S. 13.46, subd. 2 Catie Lee

71980-150 Non-consolidated corp. initial licensing letter template Private M.S. 13.46, subd. 2 Catie Lee

71980-151 Consolidated corp. relicensing letter template Private M.S. 13.46, subd. 2 Catie Lee

Page 16 of 95











Social Services

Child placement team - disposition Private M.S. 13.46, subd. 2 Catie Lee

Emergency relative FC placement info. Private M.S. 13.46, subd. 2 Catie Lee

71980-157 Adult family foster care relicensing-alternate year checklist Private M.S. 13.46, subd. 2 Catie Lee

71980-158 Rule 203 lic./relicensing checklist - consolidated stds. sites Private M.S. 13.46, subd. 2 Catie Lee

71980-159 Child placement team - initial request - corp. Private M.S. 13.46, subd. 2 Catie Lee

71980-160 Child placement team - review and disposition Private M.S. 13.46, subd. 2 Catie Lee

71980-162 Adult family foster homes bckgrnd. study tracking form Private M.S. 13.46, subd. 2 Catie Lee

71980-163 General tracking instrument Private M.S. 13.46, subd. 2 Catie Lee

71980-164 Consent to release photos/media - FC child of the year Private M.S. 13.46, subd. 2 Catie Lee

71980-165 Child dual license risk management plan Private M.S. 13.46, subd. 2 Catie Lee

71980-166 AFC grievance policy Private M.S. 13.46, subd. 2 Catie Lee

71980-167 AFFC - net study - employee BGS tracking form Private M.S. 13.46, subd. 2 Catie Lee

71980-168 Corp. CFC - relicensing/alt. year checklist (dict. outline) Private M.S. 13.46, subd. 2 Catie Lee

Page 17 of 95











Social Services

71980-169 Respite FC request (child) Private M.S. 13.46, subd. 2 Catie Lee

AFC - disaster plan Private M.S. 13.46, subd. 2 Catie Lee

71980-184 CFC field book face sheet Private M.S. 13.46, subd. 2 Catie Lee

71980-185 CFC - recruitment grant mileage reimbursement request Private M.S. 13.46, subd. 2 Catie Lee

Completed AFC - home drug and alcohol policy agreement Private M.S. 13.46, subd. 2 Catie Lee

71980-187 Med. Prov. Assessment - med. devices - quality source trg. Private M.S. 13.46, subd. 2 Catie Lee

71980-189 AFC - initial licensing checklist Private M.S. 13.46, subd. 2 Catie Lee

CFC - internal variance request form Private M.S. 13.46, subd. 2 Catie Lee

71980-201 FADS - participant's rights agreement Private M.S. 13.46, subd. 2 Catie Lee

71980-202 FADS - individual service plan Private M.S. 13.46, subd. 2 Catie Lee

71980-204 FADS - policies and procedures agreement Private M.S. 13.46, subd. 2 Catie Lee

71980-205 Placement team - youth 18-21 - extd. FC request and review Private M.S. 13.46, subd. 2 Catie Lee

71980-206 AFC individual abuse prevention plan Private M.S. 13.46, subd. 2 Catie Lee

Page 18 of 95











Social Services

71980-208 AFC - request for a variance Private M.S. 13.46, subd. 2 Catie Lee

71980-209 Placement team - youth 18-21 - ext. FC disposition Private M.S. 13.46, subd. 2 Catie Lee

71980-210 Completed FC info. mtg. letter - Adult Private M.S. 13.46, subd. 2 Catie Lee

71980-211 Completed FC info. mtg. letter - child Private M.S. 13.46, subd. 2 Catie Lee

CFC initial licensing worksheet Private M.S. 13.46, subd. 2 Catie Lee

CFC relicensing foster parent worksheet Private M.S. 13.46, subd. 2 Catie Lee

71980-214 CFC alternate year licensing worksheet Private M.S. 13.46, subd. 2 Catie Lee

Foster care correction order Private M.S. 13.46, subd. 2 Catie Lee

Adult foster care caregiver training record Private M.S. 13.46, subd. 2 Catie Lee

Physician's statement-medication admin assistance Private M.S. 13.46, subd. 2 Catie Lee

Adoptive - foster parent study - fillable Private M.S. 13.46, subd. 2 Catie Lee

Adoptive - foster parent study outline Private M.S. 13.46, subd. 2 Catie Lee

71980-NA Daily med. chart Private M.S. 13.46, subd. 2 Catie Lee

71980-NA Family disaster plan Private M.S. 13.46, subd. 2 Catie Lee

Correction order Private M.S. 13.46. subd. 2 Catie Lee

Page 19 of 95











Social Services

Completed FCC & FFC lic - applicant privacy rights Private M.S. 13.46. subd. 2 Catie Lee

Release of info. for CC licensing "Background" study Private M.S. 13.46, subd. 2 Catie Lee

72000-6 Request for special child care funding Private M.S. 13.46, subd. 2 Catie Lee

Permission to administer medication Private M.S. 13.46, subd. 2 Catie Lee

72000-11 Family child care - Placement list Private M.S. 13.46, subd. 2 Catie Lee

72000-12 Monthly activity report - CC staff Private M.S. 13.46, subd. 2 Catie Lee

CC - accident report Private M.S. 13.46, subd. 2 Catie Lee

72000-15 Completed relicensing materials letter - FCC Private M.S. 13.46, subd. 2 Catie Lee

Parent evaluation Private M.S. 13.46, subd. 2 Catie Lee

Child care record of training Private M.S. 13.46, subd. 2 Catie Lee

Reference for FCC licensing Private M.S. 13.46, subd. 2 Catie Lee

Questionnaire for CC applicants Private M.S. 13.46, subd. 2 Catie Lee

Request for variance - FCC and GFCC Private M.S. 13.46, subd. 2 Catie Lee

Animal protection plan Private M.S. 13.46, subd. 2 Catie Lee

Page 20 of 95











Social Services

Completed correction orders Private M.S. 13.46, subd. 2 Catie Lee

72000-48 History of residence Private M.S. 13.46, subd. 2 Catie Lee

Completed license approval letter - cc Private M.S. 13.46, subd. 2 Catie Lee

72000-57 Travel and activity authorization Private M.S. 13.46, subd. 2 Catie Lee

Request forCC variance Private M.S. 13.46, subd. 2 Catie Lee

CC - initial licensing evaluation Private M.S. 13.46, subd. 2 Catie Lee

Drop-in visit Private M.S. 13.46, subd. 2 Catie Lee

CC - safety checklist Private M.S. 13.46, subd. 2 Catie Lee

72000-64Completed FCC - lic. previously licensed in your county letter


72000-70 New provider tracking Private M.S. 13.46, subd. 2 Catie Lee

Variance log Private M.S. 13.46, subd. 2 Catie Lee

72000-106 Completed CC - program reporting notification Private M.S. 13.46, subd. 2 Catie Lee

72000-107 CC - licensing billing receipt Private M.S. 13.46, subd. 2 Catie Lee

Criminal background study completion letter - not disq. Private M.S. 13.46, subd. 2 Catie Lee

Page 21 of 95











Social Services

Background study documentation form Private M.S. 13.46, subd. 2 Catie Lee

72000-116 Nominate your lic. FCC prov. - prov. of the year form (lav) Private M.S. 13.46, subd. 2 Catie Lee

72000-123 Completed special needs child care funding letter Private M.S. 13.46, subd. 2 Catie Lee

72000-128 Provider action form - CCR&R Private M.S. 13.46, subd. 2 Catie Lee

A license ratios Private M.S. 13.46, subd. 2 Catie Lee

C-1 license ratios Private M.S. 13.46, subd. 2 Catie Lee



72000-131 Lic. FCC prov. recognition rating form Private M.S. 13.46, subd. 2 Catie Lee

72000-132 Licensor verif. - FCC prov. nominees Private M.S. 13.46, subd. 2 Catie Lee

Completed unlicensed family child care letter Private M.S. 13.46, subd. 2 Catie Lee

Child care initial licensing checklist Private M.S. 13.46, subd. 2 Catie Lee

72000-137 Child care special needs verified claim form Private M.S. 13.46, subd. 2 Catie Lee

72000-NAChild passenger restraint systems flyer - registration form


Page 22 of 95











Social Services

72000-NA Lic. FCC prov. of the year nomination form Private M.S. 13.46, subd. 2 Catie Lee

73000-3 Rule 25 assessment application Private M.S. 13.46, subd. 2 Catie Lee

73000-4 Residency verification form (CCDTF) Private M.S. 13.46, subd. 2 Catie Lee

73000-5Completed statement of income and health care benefits


73000-7 Placement change request Private M.S. 13.46, subd. 2 Catie Lee

73000-8 Completed your right to appeal Private M.S. 13.46, subd. 2 Catie Lee

73000-9 Service coordination form Private M.S. 13.46, subd. 2 Catie Lee

73000-11 Authorization to release Rule 25 assessment Private M.S. 13.46, subd. 2 Catie Lee

73000-12 Referral for chemical health info letter Private M.S. 13.46, subd. 2 Catie Lee

73000-16 Completed data practices rights advisory - CD (aka tennessen warning)


73000-18 ATMS entry form for Rule 25 assessments Private M.S. 13.46, subd. 2 Catie Lee

73000-19 Determination of Financial Responsibility Private M.S. 13.46, subd. 2 Catie Lee

73000-20 Completed notice to clients Private M.S. 13.46, subd. 2 Catie Lee

74000 Initial dictation Private M.S. 13.46, subd. 2 Catie Lee

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Social Services

74000-1 Request for emergency examination and hospitalization Private M.S. 13.46, subd. 2 Catie Lee

MH case management services - SPMI eligibility determinationPrivate M.S. 13.46, subd. 2 Catie Lee

Prepetition screening report Private M.S. 13.46, subd. 2 Catie Lee

Rule 79 case management and adult rehab MH svs. - eligibility form (no electronic vsn)


74000-7 Medication list/monitoring form Private M.S. 13.46, subd. 2 Catie Lee

74000-11 Prepetition screening inquiry - commitment for MI Private M.S. 13.46, subd. 2 Catie Lee

Intake form - MH unit Private M.S. 13.46, subd. 2 Catie Lee

74000-27 Data Practices rights advisory (tennessen warning) Private M.S. 13.46, subd. 2 Catie Lee

74000-29 Crisis plan (no electronic vsn) Private M.S. 13.46, subd. 2 Catie Lee

74000-31 LTCC community support plan "MH care plan" (CADI) Private M.S. 13.46, subd. 2 Catie Lee

74000-33 Annual review (waiver - checklist) Private M.S. 13.46, subd. 2 Catie Lee

74000-34 Face sheet (waiver) Private M.S. 13.46, subd. 2 Catie Lee

74000-36 Completed fax to County Attorney Private M.S. 13.46, subd. 2 Catie Lee

Page 24 of 95











Social Services

74000-38 Transportation request form Private M.S. 13.46, subd. 2 Catie Lee

74000-39 H.S.I. psychiatry referral intake data Private M.S. 13.46, subd. 2 Catie Lee

74000-40 Close case request letter Private M.S. 13.46, subd. 2 Catie Lee

74000-42 Case transfer dictation Private M.S. 13.46, subd. 2 Catie Lee

74000-44 Damage deposit reimbursement request Private M.S. 13.46, subd. 2 Catie Lee

74000-45 Diagnostic assessment outline - TCM Private M.S. 13.46, subd. 2 Catie Lee

74000-46 Case note documentation Private M.S. 13.46, subd. 2 Catie Lee

74000-48 Completed consumer stipend for MH training committee Private M.S. 13.46, subd. 2 Catie Lee

74000-55 Rule 79 peer review Private M.S. 13.46, subd. 2 Catie Lee

74000-56 Purchase of services request form Private M.S. 13.46, subd. 2 Catie Lee

74000-59Reimbursement of program expenses to service providers


74000-60 Sheriff referral for case management services Private M.S. 13.46, subd. 2 Catie Lee

74000-61 Side effects letter (430 ph#) Private M.S. 13.46, subd. 2 Catie Lee

74000-62 Request for police records by PPST Private M.S. 13.46, subd. 2 Catie Lee

Page 25 of 95











Social Services

74000-63 Agreement to participate in MN MH outcomes survey (no electronic vsn)


74000-64 Out-of-county service agreement Private M.S. 13.46, subd. 2 Catie Lee

74000-66 Daily log Private M.S. 13.46, subd. 2 Catie Lee

74000-67 Completed side effects letter (275 ph#) Private M.S. 13.46, subd. 2 Catie Lee

Face sheet - Rule 79 Private M.S. 13.46, subd. 2 Catie Lee

74000-69Completed mental health client eligibility criteria for service


74000-70 Completed extension request memo Private M.S. 13.46, subd. 2 Catie Lee

74000-72 Individual resident placement agreement (CADI) Private M.S. 13.46, subd. 2 Catie Lee

74000-73 H.S.I. transporter purchase request Private M.S. 13.46, subd. 2 Catie Lee

74000-85 Completed notification letter - receiving CADI - TBI PJ's Private M.S. 13.46, subd. 2 Catie Lee

74000-87 Request for per diem and mileage - MH advisory comm. Private M.S. 13.46, subd. 2 Catie Lee

Clinical supervision Private M.S. 13.46, subd. 2 Catie Lee

Lvl. II - MI diagnostic assessment for PASARR Private M.S. 13.46, subd. 2 Catie Lee

Level II - PASRR - cover letter Private M.S. 13.46, subd. 2 Catie Lee

Page 26 of 95











Social Services

74000-97 Housing Client Assessment Tool Private M.S. 13.46, subd. 2 Catie Lee

74000-98 Diagnostic Assessment & Eligibility Review Private M.S. 13.46, subd. 2 Catie Lee

74000-99 Hotel Stay Agreement Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Completed billing list Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Completed client's generic debt letter (CADI) Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Closing summary Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Crisis Plan (Rehab Option forms) Private M.S. 13.46, subd. 2 Catie Lee

Diagnostic assessment request letter Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Complete host county concurrance letter (CADI) Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Medical records request form Private M.S. 13.46, subd. 2 Catie Lee

74000-NA MICD (rehab option) referral form (rehab option forms) Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Completed Targeted Case Mgmt (Rule 79) opt out letter (CADI) Private M.S. 13.46, subd. 2 Catie Lee

74000-NA Completed YMCA letter with client info (CADI) Private M.S. 13.46, subd. 2 Catie Lee

75000-1 FSG - prog, documentation of annual expenditures Private M.S. 13.46, subd. 2 Catie Lee

Page 27 of 95











Social Services

75000-2 Referral for review of vol. placement of DD/EH children Private M.S. 13.46, subd. 2 Catie Lee

75000-3 ISP plan - long form Private M.S. 13.46, subd. 2 Catie Lee

75000-4 Site monitoring Private M.S. 13.46, subd. 2 Catie Lee

75000-5 Request to suspend MA deeming rules Private M.S. 13.46, subd. 2 Catie Lee

75000-7 Provider's risk management assessment and plan Private M.S. 13.46, subd. 2 Catie Lee

75000-11 Requisition Private M.S. 13.46, subd. 2 Catie Lee

75000-20 Annual waiver plan approval Private M.S. 13.46, subd. 2 Catie Lee

75000-22 Assessment of individual service needs Private M.S. 13.46, subd. 2 Catie Lee

75000-23 Income eligibility to receive services form Private M.S. 13.46, subd. 2 Catie Lee

75000-24 Discount and ID care Private M.S. 13.46, subd. 2 Catie Lee

Request for licensing corp. foster care Private M.S. 13.46, subd. 2 Catie Lee

75000-33 Intake form - DD unit Private M.S. 13.46, subd. 2 Catie Lee

75000-34 FSG - application - attachment B Private M.S. 13.46, subd. 2 Catie Lee

75000-35 FSG - budget of subsidized expenses Private M.S. 13.46, subd. 2 Catie Lee

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Social Services

75000-36 FSG - notice of grant termination (Attachment G) Private M.S. 13.46, subd. 2 Catie Lee

75000-38 Finding of fact and informal rvw, - vol. placement - DD child Private M.S. 13.46, subd. 2 Catie Lee

75000-40 Personal support services participation agreement Private M.S. 13.46, subd. 2 Catie Lee

75000-41 CSG - budget/service agreement Private M.S. 13.46, subd. 2 Catie Lee

75000-42 DRS referral Private M.S. 13.46, subd. 2 Catie Lee

75000-43 DD intake/social history info. Private M.S. 13.46, subd. 2 Catie Lee

75000-44C Completed referral for DD services letter Private M.S. 13.46, subd. 2 Catie Lee

75000-47 Personal support/respite renewal form - budget Private M.S. 13.46, subd. 2 Catie Lee

75000-48 Cert./verif. of respite prov. qualif. for unlic. out-of-home respite (Adden. ISP)


75000-53 Case record review form Private M.S. 13.46, subd. 2 Catie Lee

75000-54 Completed invite - admin. review placement DD letter Private M.S. 13.46, subd. 2 Catie Lee

75000-55 Completed (CSG) statement of informed consent Private M.S. 13.46, subd. 2 Catie Lee

75000-56 (CSG) release from liability Private M.S. 13.46, subd. 2 Catie Lee

75000-57 (CSG) designation of authorized rep. Private M.S. 13.46, subd. 2 Catie Lee

Page 29 of 95











Social Services

75000-59 Completed advisory, notice of rights and plan Private M.S. 13.46, subd. 2 Catie Lee

75000-60 Employment and alternative services plan Private M.S. 13.46, subd. 2 Catie Lee

75000-61 Service agreement Private M.S. 13.46, subd. 2 Catie Lee

75000-67 Consumer profile - DD Private M.S. 13.46, subd. 2 Catie Lee

75000-68 CSG - PDN - consumer agreement Private M.S. 13.46, subd. 2 Catie Lee

75000-69 CSG - social worker documentation Private M.S. 13.46, subd. 2 Catie Lee

75000-70 MN LTCSS - suppl. - assessment - children under 18 Private M.S. 13.46, subd. 2 Catie Lee

75000-73 DD respite financial statement Private M.S. 13.46, subd. 2 Catie Lee

75000-74 Notification of amount - parent fees - DD child respite care Private M.S. 13.46, subd. 2 Catie Lee

75000-75 APPEALS - receipt of notice letter Private M.S. 13.46, subd. 2 Catie Lee

75000-76 APPEALS - denial letter Private M.S. 13.46, subd. 2 Catie Lee

75000-77 APPEALS - tracking form Private M.S. 13.46, subd. 2 Catie Lee

75000-78 Completed personal support - warning letter Private M.S. 13.46, subd. 2 Catie Lee

75000-80 CSG - referral to fiscal supports Private M.S. 13.46, subd. 2 Catie Lee

Page 30 of 95











Social Services

75000-82 Completed Family support grant - waiting list factors Private M.S. 13.46, subd. 2 Catie Lee

75000-90 Completed acknow. - leveled case mgmt. designation and consent Private M.S. 13.46, subd. 2 Catie Lee

75000-95 ISP - transmittal svs. amendment Private M.S. 13.46, subd. 2 Catie Lee

75000-97 Verification of prescribed diet and eval. of special diet Private M.S. 13.46, subd. 2 Catie Lee

75000-98 Notice of FC benefits up to age 21 Private M.S. 13.46, subd. 2 Catie Lee

75000-99 CSG - transfer of co. of fin. responsibility Private M.S. 13.46, subd. 2 Catie Lee

75000-100 FSG - transfer of co. of fin. responsibility Private M.S. 13.46, subd. 2 Catie Lee

75000-101 Waiver management team request Private M.S. 13.46, subd. 2 Catie Lee

75000-102 Physical exam form Private M.S. 13.46, subd. 2 Catie Lee

75000-104 Verified claim form - DD Private M.S. 13.46, subd. 2 Catie Lee

75000-105 DD Unit - ISP & face-to-face tracking sheet Private M.S. 13.46, subd. 2 Catie Lee

75000-NA Completed Attachment H - FSG - waiting list Private M.S. 13.46, subd. 2 Catie Lee

75000-NA DD Review Team Referral Private M.S. 13.46, subd. 2 Catie Lee

76000 Supplies and equipment authorization Private M.S. 13.46, subd. 2 Catie Lee

Page 31 of 95











Social Services

76000-6 Quality assurance visit Private M.S. 13.46, subd. 2 Catie Lee

76000-11 AC financial eligibility report Private M.S. 13.46, subd. 2 Catie Lee

76000-24 Reg - service - 6 mo. reassessment - change Private M.S. 13.46, subd. 2 Catie Lee

76000-26 Adult intake social service referral Private M.S. 13.46, subd. 2 Catie Lee

76000-27 Completed tennessen warning Private M.S. 13.46, subd. 2 Catie Lee

76000-35 Guardianships/conservatorships Private M.S. 13.46, subd. 2 Catie Lee

76000-36 Notification to facility, medical professionals, and staff Private M.S. 13.46, subd. 2 Catie Lee

76000-38 Waiver worksheet Private M.S. 13.46, subd. 2 Catie Lee

76000-43 Purchases for clients Private M.S. 13.46, subd. 2 Catie Lee

76000-46 Completed LTCC review notice letter Private M.S. 13.46, subd. 2 Catie Lee

76000-51 Completed notice of rights Private M.S. 13.46, subd. 2 Catie Lee

76000-56 Elderly waiver services authorization form Private M.S. 13.46, subd. 2 Catie Lee

76000-72B LTTC community support plan Private M.S. 13.46, subd. 2 Catie Lee

76000-89 VA/DD TCM eligibility determination worksheet Private M.S. 13.46, subd. 2 Catie Lee

Page 32 of 95











Social Services

76000-94 Allocation change form Private M.S. 13.46, subd. 2 Catie Lee

76000-95 Notice of intent to close CADI, TBI, CAC Private M.S. 13.46, subd. 2 Catie Lee

76000-96-D1 Completed decision of committee letter - slot allocation request Private M.S. 13.46, subd. 2 Catie Lee

76000-96-D2 Completed decision of committee letter - increase - change request Private M.S. 13.46, subd. 2 Catie Lee

76000-102 Secure Blue Tracking Form Private M.S. 13.46, subd. 2 Catie Lee

76000-107 Completed AC consultation letter Private M.S. 13.46, subd. 2 Catie Lee

76000-111 Screening document info. for waiver mgmt. system entry Private M.S. 13.46, subd. 2 Catie Lee

76000-113 AC and EW waiver case checklist Private M.S. 13.46, subd. 2 Catie Lee

76000-114 AP and VA case checklist Private M.S. 13.46, subd. 2 Catie Lee

76000-116 Completed CADI-TBI case checklist Private M.S. 13.46, subd. 2 Catie Lee

76000-117 Chart cover sheet Private M.S. 13.46, subd. 2 Catie Lee

76000-119 Referral for CADI/TBI/CAC slot review committee Private M.S. 13.46, subd. 2 Catie Lee

76000-120 Ranking tool - Attachment B Private M.S. 13.46, subd. 2 Catie Lee

Page 33 of 95











Social Services

76000-122 Case assignments - LTCC Private M.S. 13.46, subd. 2 Catie Lee

76000-129 Co. waiver FC rate sheet (functional formula) Private M.S. 13.46, subd. 2 Catie Lee

76000-134 PCA tracking form Private M.S. 13.46, subd. 2 Catie Lee

76000-135 Home delivered meals eligibility determination form Private M.S. 13.46, subd. 2 Catie Lee

76000-136 Nurse's notes sheet Private M.S. 13.46, subd. 2 Catie Lee

76000-137 LTCC initial comm. Support plan - CADI Private M.S. 13.46, subd. 2 Catie Lee

76000-139 Completed physician's cover letter for guardianship Private M.S. 13.46, subd. 2 Catie Lee

76000-141 Completed rule out letter Private M.S. 13.46, subd. 2 Catie Lee

76000-142 AC prog client disclosure form Private M.S. 13.46, subd. 2 Catie Lee

76000-143 AP Assessment Private M.S. 13.46, subd. 2 Catie Lee

76000-144 Case Closing Summary Private M.S. 13.46, subd. 2 Catie Lee

76000-145 Completed investigation delay letter Private M.S. 13.46, subd. 2 Catie Lee

76000-146 Reassessment Private M.S. 13.46, subd. 2 Catie Lee

76000-147 VA investigation Private M.S. 13.46, subd. 2 Catie Lee

76000-148 Smoke detector tracking sheet (case mgr) Private M.S. 13.46, subd. 2 Catie Lee

Page 34 of 95











Social Services

76000-149 LTCC screening recommendations form Private M.S. 13.46, subd. 2 Catie Lee

76000-150 Completed false findings letter Private M.S. 13.46, subd. 2 Catie Lee

76000-151 Completed inconclusive findings letter Private M.S. 13.46, subd. 2 Catie Lee

76000-152 Completed no determination letter Private M.S. 13.46, subd. 2 Catie Lee

76000-153 Completed substantiated findings letter Private M.S. 13.46, subd. 2 Catie Lee

76000-NA Completed AC fee overdue letter Private M.S. 13.46, subd. 2 Catie Lee

76000-NA Completed AC intake public health letter Private M.S. 13.46, subd. 2 Catie Lee

76000-NA Completed AC letter to unreachable clients Private M.S. 13.46, subd. 2 Catie Lee

76000-NA Universal transfer form facesheet Private M.S. 13.46, subd. 2 Catie Lee

ASQ questionnaire Private M.S. 13.46, subd. 2 Catie Lee

ASQ-NA ASQ-3 - 4 mo questionnaire Private M.S. 13.46, subd. 2 Catie Lee




Page 35 of 95











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Page 36 of 95











Social Services

ASQ-SE-NA 6 month SE Private M.S. 13.46, subd. 2 Catie Lee








CH-NA Children's Mental Health Referral Form Private M.S. 13.46, subd. 2 Catie Lee

CH-NA ECBA Gen Referral Form Private M.S. 13.46, subd. 2 Catie Lee

CH-NA Family Treatment Program Referral Form Private M.S. 13.46, subd. 2 Catie Lee

CH-NA Life Skills-Solid Ground Class Referral Form Private M.S. 13.46, subd. 2 Catie Lee

Co. Atty.-NA Court Referral (16&17 Yr Old Student) - Truancy Private M.S. 13.46, subd. 2 Catie Lee

Co. Atty.-NA Delegation - powers by custodian - guardian Private M.S. 13.46, subd. 2 Catie Lee

Page 37 of 95











Social Services

Co. Atty.-NA Information disclosure request Private M.S. 13.46, subd. 2 Catie Lee

Co. Atty.-NA Request - issue juvenile warrrant Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Affidavit - support prehearing confinement Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Affidavit - support motion waive post-placement assessment Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Affidavit - support motion waive 1 year residency requirement Private M.S. 13.46, subd. 2 Catie Lee

CHIPS court review report Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Child out-of-home and over 16 court report Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Child out-of-home and under 16 court report Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Communication and contact agreement and order Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Consent of parent to sdoption waiver notice adoption hearing Private M.S. 13.46, subd. 2 Catie Lee

Consent adoption child 14 and older Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Demand for notice - probate Private M.S. 13.46, subd. 2 Catie Lee

Court-NA ECT - affidavit Private M.S. 13.46, subd. 2 Catie Lee

Page 38 of 95











Social Services

Court-NA ECT - petition Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Examiners support statement Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Exhibit A Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Findings-Conclusions order for judgement and decree of adoption Private M.S. 13.46, subd. 2 Catie Lee

Court.-NA Formal review request Private M.S. 13.46, subd. 2 Catie Lee

Court.-NA Informal review order Private M.S. 13.46, subd. 2 Catie Lee

Court.-NA Motion to waive 1 year residency requirement Private M.S. 13.46, subd. 2 Catie Lee

Court.-NA Motion to waive post-placement assessment Private M.S. 13.46, subd. 2 Catie Lee

Notice child returned to care parent or legal custodian Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Order of probation - CHIPS Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Order of probation - delinquency (court) Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Order waiving 1 year residence requirement Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Order waiving post-placement assessment Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Petition - authoriz. - impose treatment (ITP) - req. hearing and affidavit


Page 39 of 95











Social Services

Petition - judicial commitment Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Petition - judicial early intervention Private M.S. 13.46, subd. 2 Catie Lee

Petition - stepparent adoption (uncontested) Private M.S. 13.46, subd. 2 Catie Lee

Physician's statement - support - cnsrvtshp. - fillable Private M.S. 13.46, subd. 2 Catie Lee

Court-NA Physician's statement - support ward cnsrvts inability to attend hearing


Court-NA Probation violation report Private M.S. 13.46, subd. 2 Catie Lee

Stepparent adoption affidavit checklist if post-placement assessment waived


DHS-33 Appeal to state agency Private M.S. 13.46, subd. 2 Catie Lee

DHS-35 State agency appeals summary Private M.S. 13.46, subd. 2 Catie Lee

DHS-139 Agreement between foster parents and placement agency Private M.S. 13.46, subd. 2 Catie Lee

Report of adoptive placement Private M.S. 13.46, subd. 2 Catie Lee

Report to court petition for adoption Private M.S. 13.46, subd. 2 Catie Lee

DHS-250 MN DHS div. of licensing family systems application Private M.S. 13.46, subd. 2 Catie Lee

Page 40 of 95











Social Services

Adoption placement agreement for child under state guardianship Private M.S. 13.46, subd. 2 Catie Lee

Home safety checklist Private M.S. 13.46, subd. 2 Catie Lee

DHS-968 Adoptive applicant registration state adoption exchange (2004) Private M.S. 13.46, subd. 2 Catie Lee

Interstate compact - placement of children summary Private M.S. 13.46, subd. 2 Catie Lee

DHS-1715 Family day care admission and arrangements Private M.S. 13.46, subd. 2 Catie Lee

DHS-1795 SSI interim assistance agreement Private M.S. 13.46, subd. 2 Catie Lee

DHS-1795a Interim assist agreement Private M.S. 13.46, subd. 2 Catie Lee

DHS-1956 Consent of child over 14 years of age Private M.S. 13.46, subd. 2 Catie Lee

Physician's report Private M.S. 13.46, subd. 2 Catie Lee

Application for social services Private M.S. 13.46, subd. 2 Catie Lee

DHS-2243 Gen. authorization - release of info - assets Private M.S. 13.46, subd. 2 Catie Lee

Request for fire inspection Private M.S. 13.46, subd. 2 Catie Lee

DHS-2494 Report of vulnerable adult maltreatment Private M.S. 13.46, subd. 2 Catie Lee

Page 41 of 95











Social Services

DHS-2630 AC program eligibility worksheet - 180 day - both Private M.S. 13.46, subd. 2 Catie Lee

DHS-2630A AC program eligibility worksheet - 180 day - one spouse Private M.S. 13.46, subd. 2 Catie Lee

Floor and escape plan Private M.S. 13.46, subd. 2 Catie Lee

Letter to owner of unlicensed CC home Private M.S. 13.46, subd. 2 Catie Lee

DHS-2727 Information and signature sheet for PAS/EW/AC/CADI/CAC/TBI Private M.S. 13.46, subd. 2 Catie Lee

DHS-2780 Client placement authorization - CCDTF Private M.S. 13.46, subd. 2 Catie Lee

DHS-2794 Rule 25 assessment and placement summary Private M.S. 13.46, subd. 2 Catie Lee

DHS-2828 Notice of action - home and comm. bases waiver svs. Private M.S. 13.46, subd. 2 Catie Lee

DHS-3767 Cost Effective Insurance Info - Employer or Ins Co Private M.S. 13.46, subd. 2 Catie Lee

DHS-3767A Required Informaton from an Insurer for an MA Member's Cost Effective Health Insurance Determination

Private M.S.13.46,subd.2 Catie Lee

DHS-3767D Cost Effective Health Insurance Referral to a MA Member Private M.S.13.46,subd.2 Catie Lee

DHS-3767E Your Health Insurance is Cost Effective Private M.S.13.46,subd.2 Catie Lee

DHS-3767F Your Health Insurance is Not Cost Effective Private M.S.13.46,subd.2 Catie Lee

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Social Services

DHS-3767G Medical Assistance will Stop Paying your Health Insurance Premium Private M.S.13.46,subd.2 Catie Lee

DHS-3767H Application for a Cost Effective Hardship Waiver Private M.S.13.46,subd 2 Catie Lee

DHS-6737I Hardship Determination for Cost Effective Health Insurance Private M.S.13.46, subd 2 Catie Lee

DHS-6737J Agency Appeals Summary for Cost Effective Health Insurance Private M.S.13.46,subd 2 Catie Lee

DHS-2919A Verification request Form A for eligibility for services Private M.S. 13.46, subd. 2 Catie Lee

DHS-2919B Verification request Form B for eligibility for services Private M.S. 13.46, subd. 2 Catie Lee

DHS-2925 LTCC community support plan Private M.S. 13.46, subd. 2 Catie Lee

DHS-2952 Authorization - release of info. - residence and shelter expenses Private M.S. 13.46, subd. 2 Catie Lee

DHS-3067 DD screening document Private M.S. 13.46, subd. 2 Catie Lee

DHS Service agreement Private M.S. 13.46, subd. 2 Catie Lee

DHS-3141 Variance request (6-07 - use lic. online version?) Private M.S. 13.46, subd. 2 Catie Lee

DHS Completed TCM data transmittal Private M.S. 13.46, subd. 2 Catie Lee

DHS-3161 Agreement to use designated provider Private M.S. 13.46, subd. 2 Catie Lee

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Social Services

DHS Emergency relative FC license application Private M.S. 13.46, subd. 2 Catie Lee

DHS-3219 Emergency rel. FC notice - bckgrnd. study (old - ck.) Private M.S. 13.46, subd. 2 Catie Lee

DHS-3235 Background and health history Private M.S. 13.46, subd. 2 Catie Lee

DHS-3243 CEP intake form - VA maltreatment report - disclosure Private M.S. 13.46, subd. 2 Catie Lee

DHS-3244 PCA assessment and svs. plan Private M.S. 13.46, subd. 2 Catie Lee

DHS-3244A MA - home care service plan Private M.S. 13.46, subd. 2 Catie Lee

DHS-3324 Div. of lic. - family systems unit application Private M.S. 13.46, subd. 2 Catie Lee

DHS-3340 Asset assessment results Private M.S. 13.46, subd. 2 Catie Lee

DHS-3417 MN health care prog. application Private M.S. 13.46, subd. 2 Catie Lee

DHS-3423 Request - questions for GAMC Private M.S. 13.46, subd. 2 Catie Lee

DHS-3426 LTCC prog. - OBRA level I criteria - screening for MR/MI Private M.S. 13.46, subd. 2 Catie Lee

DHS-3427 LTC screening document Private M.S. 13.46, subd. 2 Catie Lee

DHS-3428 MN LTCC services assessment form Private M.S. 13.46, subd. 2 Catie Lee

DHS-3428A MN LTCC services assessment form: SW and PHE sections Private M.S. 13.46, subd. 2 Catie Lee

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Social Services

DHS-3428D PCA svc. Plan for waiver participant Private M.S. 13.46, subd. 2 Catie Lee

DHS-3428E Consent for release of your name to center for ind. living Private M.S. 13.46, subd. 2 Catie Lee

DHS-3445 Prog. - eligibility verification letter Private M.S. 13.46, subd. 2 Catie Lee

DHS-3457 Eval. report - lvl. II PAS for persons w/MI Private M.S. 13.46, subd. 2 Catie Lee

DHS-3471 TBI waiver assessment and elig. determination Private M.S. 13.46, subd. 2 Catie Lee

DHS-3471A TBI waiver assessment and elig. determination instr./wksht. Private M.S. 13.46, subd. 2 Catie Lee

DHS-3471B TBI waiver elig. and documentation Private M.S. 13.46, subd. 2 Catie Lee

DHS-3478 Title IV-E Foster Care Supplement ot the Health Care Programs Application


DHS-3543 Request - payment of long-term care svs. Private M.S. 13.46, subd. 2 Catie Lee

DHS-3614 Emergency back-up plan Private M.S. 13.46, subd. 2 Catie Lee

DHS-3848 Related conditions checklist (DD) Private M.S. 13.46, subd. 2 Catie Lee

DHS-4007 County of financial responsibility Private M.S. 13.46, subd. 2 Catie Lee

DHS-4015 Prov. enrollment application Private M.S. 13.46, subd. 2 Catie Lee

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DHS-4138 Provider agreement Private M.S. 13.46, subd. 2 Catie Lee

DHS-4147a Case mgr. guide - determining ICF-MR level - care - ICF - MR - MR - RD wvr


DHS-4248 Evaluative report - Lvl II - preadm. screening - persons DD/RC Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258a MN adoption and foster care application Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258b Eligibility for individual fact sheet Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258c Agency home study checklist for eligibility Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258d Home study assessment (fillable) Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258e Home study assessment update (fillable) Private M.S. 13.46, subd. 2 Catie Lee

DHS-4258f Family disaster plan Private M.S. 13.46, subd. 2 Catie Lee

DHS-4266 Interstate compact - placement - children - request Private M.S. 13.46, subd. 2 Catie Lee

DHS-4267 Interstate compact - placement - children - report placement status Private M.S. 13.46, subd. 2 Catie Lee

DHS-4268 Interstate compact - placement children asss. of admin. Private M.S. 13.46, subd. 2 Catie Lee

DHS-4369 Notice of social service action Private M.S. 13.46, subd. 2 Catie Lee

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DHS-4488 Letter of co. acknow. - new MR-RC home and CBWS prov. Private M.S. 13.46, subd. 2 Catie Lee

DHS-4556 Annual community support plan eligibility Private M.S. 13.46, subd. 2 Catie Lee

DHS-4602 Med. condition documentation form Private M.S. 13.46, subd. 2 Catie Lee

DHS-4689A Screening deletion request - DD Private M.S. 13.46, subd. 2 Catie Lee

DHS-4689B Service agreement fax - DD Private M.S. 13.46, subd. 2 Catie Lee

DHS-4689C Screening document fax - DD Private M.S. 13.46, subd. 2 Catie Lee

DHS-4690 Communication to physician of PCA svs. Private M.S. 13.46, subd. 2 Catie Lee

DHS-4801 AC estate claim referral worksheet Private M.S. 13.46, subd. 2 Catie Lee

DHS-4927 Completed monthly crib safety inspection form Private M.S. 13.46, subd. 2 Catie Lee

DHS-5017 Summary of Diagnostic Findings Private M.S. 13.46, subd. 2 Catie Lee

DHS-5178 Emergency relative placement - FC referral form Private M.S. 13.46, subd. 2 Catie Lee

DHS-5204 Rule 25 assessment Private M.S. 13.46, subd. 2 Catie Lee

DHS-5223 Combined application form (CAF) Private M.S. 13.46, subd. 2 Catie Lee

DHS-5224 ICWA SW checklist Private M.S. 13.46, subd. 2 Catie Lee

DHS-5225 Data practices agreement (ICWA) Private M.S. 13.46, subd. 2 Catie Lee

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DHS-5227 Notice to tribe of svs. to Indian child Private M.S. 13.46, subd. 2 Catie Lee

DHS-5410 FC candidacy determination form Private M.S. 13.46, subd. 2 Catie Lee

DHS-5788 CDCS - alt. treatment form - MHCP - enr. Phys. Private M.S. 13.46, subd. 2 Catie Lee

DHS-5876 Parent directive - infant sleep position Private M.S. 13.46, subd. 2 Catie Lee

DHS-5883 Substantiated perpetrator reporting form Private M.S. 13.46, subd. 2 Catie Lee

DHS-5887 DD - additional square footage checklist Private M.S. 13.46, subd. 2 Catie Lee

DHS-6123 Ref. for disability determination Private M.S. 13.46, subd. 2 Catie Lee

DHS-6124 Authorization - disclose info. - DD Private M.S. 13.46, subd. 2 Catie Lee

DHS-6125 Adult Disability Worksheet Private M.S. 13.46, subd. 2 Catie Lee

DHS-6249 LOCUS recording form Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-138675 Consent/authorization for release of information Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-138632 Supplement to application (DHS-3324) Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-143369 Variance request form (family systems) Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-143404 Wading Pool Letter & Parent Consent Private M.S. 13.46, subd. 2 Catie Lee

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DHS-16-143406 Swimming Pools in Child Care Homes Parent Consent Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-143519 Correction order Private M.S. 13.46, subd. 2 Catie Lee

DHS-16-148050 MN 10 x 10 (NO bipolar - schizo title) Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA CDCS - FSE vendor notification Private M.S. 13.46, subd. 2 Catie Lee

FA Functional assessment Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA Immediate risk of harm determination worksheet Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA Individual abuse prevention plan - IAPP Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA MN self-sufficiency matrix Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA Req. - reconsideration of disqualification form Private M.S. 13.46, subd. 2 Catie Lee

DHS-NA Rule 203 - AFC lic. cklst. - consolidated stds. sites Private M.S. 13.46, subd. 2 Catie Lee

EA-263 Employment verification Private M.S. 13.46, subd. 2 Catie Lee

EA-485 Placement authorization Private M.S. 13.46, subd. 2 Catie Lee

EA-704 EBT card maintenance Private M.S. 13.46, subd. 2 Catie Lee

EMACS-NA Inpatient referral Private M.S. 13.46, subd. 2 Catie Lee

EMACS-NA Referral form Private M.S. 13.46, subd. 2 Catie Lee

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FAP-NA Child prot demographic & enrollment data form Private M.S. 13.46, subd. 2 Catie Lee

FAP-NA Permission for enrollment Private M.S. 13.46, subd. 2 Catie Lee

FGDM-NA Consent to Release Info - FGDM Private M.S. 13.46, subd. 2 Catie Lee

FGDM-NA Preparation Guide for Participants - FGDM Private M.S. 13.46, subd. 2 Catie Lee

FGDM-NA Provider Release Form - FGDM Private M.S. 13.46, subd. 2 Catie Lee

FGDM-NA Referral Form - FGDM Private M.S. 13.46, subd. 2 Catie Lee

FGMI-NA Foundations group of MN referral form Private M.S. 13.46, subd. 2 Catie Lee

FR-NA Intake & Assessment Form - Frazier Recovery Homes Private M.S. 13.46, subd. 2 Catie Lee

FS-NA Address book request for supplier - Fin. Svs. Private M.S. 13.46, subd. 2 Catie Lee

MC-NA Paratransit Eligibility Certification Questionnaire Private M.S. 13.46, subd. 2 Catie Lee

CP/CW TCM Plan Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Collaborative - care plan - MSHO - SSC Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica care coordinator medication exception request form Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica denial/termination/reduction (DTR) form - 2010 Private M.S. 13.46, subd. 2 Catie Lee

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MED-NA Medica MD letter after visit Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica MD letter no visit completed Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica member enrollment transfer form Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica MSHO initial welcome letter - new client Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica MSHO welcome letter - current client Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Medica MSHO welcome letter - new client - unable to reach Private M.S. 13.46, subd. 2 Catie Lee

MED-NA Revised SNBC Assessment Template Private M.S. 13.46, subd. 2 Catie Lee

DHS-6322 Initial DBT Authorization Form

DHS-4695 Mental health DBT referral form Private M.S. 13.46, subd. 2 Catie Lee

MDH-NA Affidavit - disclosure or non-disclosure - orig birth cert. - adopted child


MDH-NA Certificate of adoption Private M.S. 13.46, subd. 2 Catie Lee

MDH-NA Child care immunization record Private M.S. 13.46, subd. 2 Catie Lee

MDH-NA MN birth record appl. - cert. of birth - fee worksheet Private M.S. 13.46, subd. 2 Catie Lee

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MDH-NA MN birth record appl. - certified copy Private M.S. 13.46, subd. 2 Catie Lee

MDH-NA MN birth record appl. - verification Private M.S. 13.46, subd. 2 Catie Lee

MDH-NA MN std. consent form - release health info. - rel. #1 (blank/CD/CG/FL/STW vsns.)


MJUA-NA MJUA - incident claim form Private M.S. 13.46, subd. 2 Catie Lee

MN CCR&R Business Info-All Year - Family Child Care Form Private M.S. 13.46, subd. 2 Catie Lee

MN-DNR-NA Permanent angling license Private M.S. 13.46, subd. 2 Catie Lee

MN-PS-33117-04 Eligibility verif. - reduced fee ID card Private M.S. 13.46, subd. 2 Catie Lee

MN-SFM-NA Owner permission - state fire marshall inspection Private M.S. 13.46, subd. 2 Catie Lee

Bridges application Private M.S. 13.46, subd. 2 Catie Lee

MN HFA-NA Long-term homeless housing status form Private M.S. 13.46, subd. 2 Catie Lee

Crisis housing fund - consent - release - info. forms Private M.S. 13.46, subd. 2 Catie Lee

MNHP-NA Crisis housing fund - payment request form Private M.S. 13.46, subd. 2 Catie Lee

MNTS-NA MN Telephone Svc Discount Application Private M.S. 13.46, subd. 2 Catie Lee

NA Creative senior dining referral form - Wash. Co. Private M.S. 13.46, subd. 2 Catie Lee

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OEO-NA ESGP - Intake Form - HMIS-Single Clients Private M.S. 13.46, subd. 2 Catie Lee

OEO-NA ESPG - Svc End Form - HMIS-Single Clients Private M.S. 13.46, subd. 2 Catie Lee

OEO-NA HMIS Data Privacy Notice & Consent-MN Private M.S. 13.46, subd. 2 Catie Lee

Ombudsman-NA Death report Private M.S. 13.46, subd. 2 Catie Lee

Ombudsman-NA Death - serious injury fax cover Private M.S. 13.46, subd. 2 Catie Lee

Ombudsman-NA Serious injury report Private M.S. 13.46, subd. 2 Catie Lee

Optage-NA HDM Referral Form - Optage Private M.S. 13.46, subd. 2 Catie Lee

PFJ-NA EBP Stages of Change Private M.S. 13.46, subd. 2 Catie Lee

PFJ-NA Referral for Partnering for Jobs Private M.S. 13.46, subd. 2 Catie Lee

People-NA Referral Form-Nursing Svs-MH - New & Cover Letter Private M.S. 13.46, subd. 2 Catie Lee

PH-NA Completed Water Sample Info. Private M.S. 13.46, subd. 2 Catie Lee

PSC-NA Pediatric systems checklist Private M.S. 13.46, subd. 2 Catie Lee

REG-NA Patient authorization - release protected info Private M.S. 13.46, subd. 2 Catie Lee

REM-NA Adaptation request form Private M.S. 13.46, subd. 2 Catie Lee

Sal. Army-NA Agency referral form Private M.S. 13.46, subd. 2 Catie Lee

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SB-NA Sec.Blue-Tracking Form-76000.102 Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA AP - Adult protection minor service Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA AP - Home care client satisfaction survey Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA AP - quality assurance visit Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA AP - VA investigation Private M.S. 13.46, subd. 2 Catie Lee

CH MH - advisory and notice of rights - SED child in vol. placement Private M.S. 13.46, subd. 2 Catie Lee

CH MH - referral - review vol. placement - DD or emotionally disturbed children (SED)


CP - case summary/closing Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - checklist for youth 16+ (in care) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - 90-day TPR review - child 16 and over Private M.S. 13.46, subd. 2 Catie Lee

CHIPS Request Private M.S. 13.46, subd. 2 Catie Lee

CHIPs Court Review Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - child at home - ICWA Private M.S. 13.46, subd. 2 Catie Lee

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SSIS-NA CP - court report - child out of home Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - child out-of-home and over 16 Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - child out-of-home and over 16 - ICWA Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - child out-of-home and under 16 Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - child out-of-home and under 16 - ICWA Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - formal review request Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - informal review order Private M.S. 13.46, subd. 2 Catie Lee

CP - court report - informal review - vol. placement - DD/emot. disturbed


SSIS-NA CP - court report - order of probation - delinquency Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - court report - probation violation report Private M.S. 13.46, subd. 2 Catie Lee

CP - disposition of child protection report - notice to mandated reporters


CP - family safety plan Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - permanency team review and disposition Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA CP - request for police records Private M.S. 13.46, subd. 2 Catie Lee

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CP - Youth 18-21 receiving foster care benefits Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA DD - ISP - individual service plan (long form) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA DD - ISP - Individual service plan - Form B (short form) Private M.S. 13.46, subd. 2 Catie Lee

Intake - CP - case assessment Private M.S. 13.46, subd. 2 Catie Lee

CP Mandated Reporter's Screening Notice Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Intake - CP screen out maltreatment/mandated reporter - supervisor Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Intake - CP screen out maltreatment/vol. reporter - screener Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Intake - CP screen out maltreatment/vol. reporter - supervisor Private M.S. 13.46, subd. 2 Catie Lee

IV-E - Title IV-E Checklist Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - annual review Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - blue and white Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - closing summary Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment Report 1: 60-90 day treatment report Private M.S. 13.46, subd. 2 Catie Lee

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SSIS-NA MH - 60 day Commitment Report to Court Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment Report 6-month (no extension requested) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment court report for revocation of PD Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment Report affidavit Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment Report 6: apprehension info. sheet Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - Commitment Report 7: notice of intent to revoke PD Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - confirmation of medications Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - consumer indep. living and employment status Private M.S. 13.46, subd. 2 Catie Lee

MH -crisis plan Private M.S. 13.46, subd. 2 Catie Lee

MH - functional assessment Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - health care referral - STW/CG office Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - individual community support plan Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - initial dictation Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - initial nursing assessment Private M.S. 13.46, subd. 2 Catie Lee

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SSIS-NA MH - medication list/monitoring form Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH - nursing/medical assessment Private M.S. 13.46, subd. 2 Catie Lee

MH - prepetition screening report Private M.S. 13.46, subd. 2 Catie Lee

MH TCM Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - HealthPartners need for DTR notification form Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - Medica behav. health TCM form (assessment) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - Medica behav. health member rights Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - Medica behav. health TCM request (initial) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - Medica need for DTR notification form Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - U Care BHP discharge summary Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - U Care DTR notification form Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - U Care member rights packet Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH insurance - U Care targeted case management form Private M.S. 13.46, subd. 2 Catie Lee

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SSIS-NA MH SOC1 - court report: stayed order of commitment report (90 day)


SSIS-NA MH SOC2 - court report: stayed order of commitment report (request to dismiss)


SSIS-NA MH SOC3 - court report: request extension of stayed order of commitment


SSIS-NA MH SOC4 - court report: request revocation of stayed order of commitment report


SSIS-NA MH SOC5 - court report: extension of stayed order of commitment report


SSIS-NA MH SOC6 - court report: affidavit Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH SOD1 - court report: stayed order for dismissal report (90 days) Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH SOD2 - court report: stayed order for dismissal Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA MH SOD3 - court report: request for a hearing on stayed order for dismissal


SSIS-NA MH SOD4 - court report: request for a hearing on continuance for dismissal


SSIS-NA Placement Team - Child - Initial Request & Disposition Private M.S. 13.46, subd. 2 Catie Lee

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SSIS-NA Placement Team - Child - Respite Care Request Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Placement Team - Child - Review & Disposition Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Truancy - diversion contract - education neglect Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Truancy - diversion contract - truancy Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Truancy - parent - educational neglect letter Private M.S. 13.46, subd. 2 Catie Lee

SSIS-NA Truancy - parent - truancy letter Private M.S. 13.46, subd. 2 Catie Lee

Think Small-NA MN Child Care Business Form Private M.S. 13.46, subd. 2 Catie Lee

Totems-NA Referral and initial assessment form Private M.S. 13.46, subd. 2 Catie Lee

TrnstLnk-NA Ticket order form Private M.S. 13.46, subd. 2 Catie Lee

Family based and outpatient svs. referral form Private M.S. 13.46, subd. 2 Catie Lee

Universal transfer form Private M.S. 13.46, subd. 2 Catie Lee

UMN-NA Authorization - release protected health info (4-08) Private M.S. 13.46, subd. 2 Catie Lee

WC-G-5 Completed Social welfare fund instructions Private M.S. 13.46, subd. 2 Catie Lee

WC-G-10 Verified claim form Private M.S. 13.46, subd. 2 Catie Lee

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WC-G-22 Referral - to Family Service Private M.S. 13.46, subd. 2 Catie Lee

WC-G-41 Request for interpreter services Private M.S. 13.46, subd. 2 Catie Lee

YIT-NA Consent to Release Info-Youth in Transition Private M.S. 13.46, subd. 2 Catie Lee

YIT-NA Completed Prep Guide-Participants-Youth In Transition Private M.S. 13.46, subd. 2 Catie Lee

Form Signs of Safety Mapping Private M.S. 13.46, subd. 2 Catie Lee

SSIS - NA Parent Support and Outreach Case Plan Private M.S. 13.46, subd. 3 Catie Lee

SSIS - NA Family Assessment Case Plan Private M.S. 13.46, subd. 4 Catie Lee

SSIS - NA Child Welfare Case Plan Private M.S. 13.46, subd. 5 Catie Lee

SSIS - NA Minor Parent out of Home Placement Case Plan Private M.S. 13.46, subd. 6 Catie Lee

SSIS - NA Independent Living Case Plan Private M.S. 13.46, subd. 7 Catie Lee

CPS - Form Help Me Grow Referral Private M.S. 13.46, subd. 8 Catie Lee

FormStructured Decision Making Tools: Needs/Strengths Assessment, Risk Assessment, Child Well Being Tool, Risk Reassessment


Mental Health Screening Private M.S. 13.46, subd. 10 Catie Lee

SSIS TCM Annual review Private M.S. 13.46, subd. 11 Catie Lee

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Form SED/SPMI Verifcation Private M.S. 13.46, subd. 12 Catie Lee

SSIS CMH Individual Family Coomunity Support Plan Private M.S. 13.46, subd. 13 Catie Lee

Letter CMH Eligibility Determination Private M.S. 13.46, subd. 14 Catie Lee

CMH Social History Private M.S. 13.46, subd. 15 Catie Lee

CASII Child and Adolescent Service Intensity Instrument Private M.S. 13.46, subd. 16 Catie Lee

ECSII Early Childhood Service Intensity Instrument Private M.S. 13.46, subd. 17 Catie Lee

SDQ Strengths and Difficulties Questionnaire Private M.S. 13.46, subd. 18 Catie Lee

SSIS AMH Individual Community Support Plan Private M.S. 13.46, subd. 19 Catie Lee

SSIS Clinical Supervision Documentation Private M.S. 13.46, subd. 20 Catie Lee

ACT Assertive Community Treatment Referral Private M.S. 13.46, subd. 21 Catie Lee

ARMHS Adult Rehabilitative Mental Health Services Referral Private M.S. 13.46, subd. 22 Catie Lee

AP TEAM Consults Private M.S. 13.46, subd. 23 Catie Lee

request for Emergency Hospitalization Private M.S. 13.46, subd. 24 Catie Lee

Witness Documentation Report Private M.S. 13.46, subd. 25 Catie Lee

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Stipulated Agreement Private M.S. 13.46, subd. 26 Catie Lee

Early Intervention Decision Tree Private M.S. 13.46, subd. 27 Catie Lee

request for an Order for Apprehension Private M.S. 13.46, subd. 28 Catie Lee

Examiner's Statement in Support of Petition for Judicial Commitment Private M.S. 13.46, subd. 29 Catie Lee

Norice for MI/MR/CD Private M.S. 13.46, subd. 30 Catie Lee

SW 18 Discretionary Funds Request Private M.S. 13.46, subd. 31 Catie Lee

CP TEAM Consult Private M.S. 13.46, subd. 32 Catie Lee

Placement Consideration Private M.S. 13.46, subd. 33 Catie Lee

Taking a Child Into Custody Private M.S. 13.46, subd. 34 Catie Lee

Child's Health History and Physical Examination Private M.S. 13.46, subd. 35 Catie Lee

SCHS Disaster Preparedness Child Placement Private M.S. 13.46, subd. 36 Catie Lee

Permanency Tracking Log Private M.S. 13.46, subd. 37 Catie Lee

SSIS Case Load List Private M.S. 13.46, subd. 38 Catie Lee

Family Assessment Funds request Private M.S. 13.46, subd. 39 Catie Lee

PSOP Funds Request Private M.S. 13.46, subd. 40 Catie Lee

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Birth Parent Social/Medical History Private M.S. 13.46, subd. 41 Catie Lee

Authorization for Release of Information from BCA Private M.S. 13.46, subd. 42 Catie Lee

Home Study Update Private M.S. 13.46, subd. 43 Catie Lee

Report of Termination Private M.S. 13.46, subd. 44 Catie Lee

Information for Attorney to file Adoption Private M.S. 13.46, subd. 45 Catie Lee

Post Adoption Services Rights Private M.S. 13.46, subd. 46 Catie Lee

Consent of Parent of Minor Parent to Adoption Private M.S. 13.46, subd. 47 Catie Lee

Placing Agency Reimbursement Agreement Private M.S. 13.46, subd. 48 Catie Lee

Supplemental Adoption Assistance Needs Assessment Private M.S. 13.46, subd. 49 Catie Lee

3324 Request for Licensure Private M.S. 13.46, subd. 50 Catie Lee

Fingerprint Cards Private M.S. 13.46, subd. 51 Catie Lee

SCHS CMH Contract Private M.S. 13.46, subd. 52 Catie Lee

Your Privacy Rights Private M.S. 13.46, subd. 53 Catie Lee

Consent for Release of Information Private M.S. 13.46, subd. 54 Catie Lee

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SSIS Application Private M.S. 13.46, subd. 55 Catie Lee

DHS-2828 Notice of Agency Action Private M.S. 13.46, subd. 56 Catie Lee

DHS-33 Appeal Form Private M.S. 13.46, subd. 57 Catie Lee

RIDES request Private M.S. 13.46, subd. 58 Catie Lee

Vouchers Private M.S. 13.46, subd. 59 Catie Lee

Service Arrangement Private M.S. 13.46, subd. 60 Catie Lee

DHS-3070 Service Agreement Private M.S. 13.46, subd. 61 Catie Lee

Individual Emergency Information Sheet Private M.S. 13.46, subd. 62 Catie Lee

Emergency Back-up Plan Private M.S. 13.46, subd. 63 Catie Lee

SSIS Intake Report Private M.S. 13.46, subd. 64 Catie LeeDD FormsDHS-2817 Application for Waiver Services Private M.S. 13.46, subd. 65 Catie Lee

DD Intake Log Private M.S. 13.46, subd. 66 Catie Lee

Social History Private M.S. 13.46, subd. 67 Catie Lee

Risk Management Plan Private M.S. 13.46, subd. 68 Catie Lee

Initial Checklist Private M.S. 13.46, subd. 69 Catie Lee

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Annual Checklist Private M.S. 13.46, subd. 70 Catie Lee

DHS-6768 CM Cost Report Private M.S. 13.46, subd. 71 Catie Lee

DHS-3848 Related Conditions Checklist Private M.S. 13.46, subd. 72 Catie Lee

DHS guide Guide to Determining ICF/DD Level of Care Private M.S. 13.46, subd. 73 Catie Lee

DHS-3067 DD Screening Document Private M.S. 13.46, subd. 74 Catie Lee

Individual Service Plan Private M.S. 13.46, subd. 75 Catie Lee

Family Support Grant Packet Private M.S. 13.46, subd. 76 Catie Lee

Case Management Assessment Private M.S. 13.46, subd. 77 Catie Lee

Report Death/Serious Injury Private M.S. 13.46, subd. 78 Catie Lee

Meeting Attendance Sheet Private M.S. 13.46, subd. 79 Catie Lee

Contract to Act as Legal Representative for State Wards Private M.S. 13.46, subd. 80 Catie Lee

Unlicensed Provider Agreement Private M.S. 13.46, subd. 81 Catie Lee

VA/DD TCM Eligibility Sheet Private M.S. 13.46, subd. 82 Catie Lee

Transition Planning Worksheet Private M.S. 13.46, subd. 83 Catie Lee

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Social Services

DD Tracking Form Private M.S. 13.46, subd. 84 Catie Lee

Guardianship Court Orders Private M.S. 13.46, subd. 85 Catie Lee

DNR/DNI Orders Private M.S. 13.46, subd. 86 Catie Lee

Host County Concurrence Private M.S. 13.46, subd. 87 Catie Lee

Provider Reports Private M.S. 13.46, subd. 88 Catie Lee

Psychological/Medical Reports Private M.S. 13.46, subd. 89 Catie Lee

Individual Education Plans Private M.S. 13.46, subd. 90 Catie Lee

Amended Service Plan Private M.S. 13.46, subd. 91 Catie Lee

Individual Waiver Budget Review Private M.S. 13.46, subd. 92 Catie Lee

Waiver Management Systems Reports (online) Private M.S. 13.46, subd. 93 Catie Lee

Budget Allocation Methodology reports (online) Private M.S. 13.46, subd. 94 Catie Lee

Disability waivers Rate Management Tool (online) Private M.S. 13.46, subd. 95 Catie Lee

Waiver Alliance Region 6W Alliance Waiver Slot Pool Request Private M.S. 13.46, subd. 96 Catie Lee

Waiver Alliance Region 6W Alliance Funding Request Private M.S. 13.46, subd. 97 Catie Lee

Waiver Alliance Region 6W Waiver Management System Reports (online) Private M.S. 13.46, subd. 98 Catie Lee

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Social Services

Chemical Use Assessment Fee Determination Private M.S. 13.46, subd. 99 Catie Lee

Confidentiality of Alcohol and Drug Abuse Patient Records Private M.S. 13.46, subd. 100 Catie Lee

Right to Second Assessment Private M.S. 13.46, subd. 101 Catie Lee

Authorization to Obtain, Disclose and Exchange Confidential Information


CCDTF Eligibility Questionnaire/Health Insurance Information Private M.S. 13.46, subd. 103 Catie Lee

DHS-2780 Client Placement Authorization - CCDTF Private M.S. 13.46, subd. 104 Catie Lee

DHS-2794 Rule 25 Assessment and Placement Summary Private M.S. 13.46, subd. 105 Catie Lee

DHS-5204 Rule 25 Assessment Private M.S. 13.46, subd. 106 Catie Lee

Treatment Reports Private M.S. 13.46, subd. 107 Catie Lee Court Orders Private M.S. 13.46, subd. 108 Catie Lee

Psychological/Medical Reports Private M.S. 13.46, subd. 109 Catie Lee

Rule 25 Referral Log Private M.S. 13.46, subd. 110 Catie Lee

Detox Log Private M.S. 13.46, subd. 111 Catie Lee

VA/AP Forms Private M.S. 13.46, subd. 112 Catie Lee

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Adult Protection Team Consult Form Private M.S. 13.46, subd. 113 Catie Lee

Adult Protection Case Consult Log Private M.S. 13.46, subd. 114 Catie Lee

Common Entry Point Private M.S. 13.46, subd. 115 Catie Lee

Structured Decision Making Tools (online) Private M.S. 13.46, subd. 116 Catie Lee

Common Entry Point Report Log Private M.S. 13.46, subd. 117 Catie Lee

Common Entry Point Checklist for VA Reports Private M.S. 13.46, subd. 118 Catie Lee

Vulnerable Adult Investigation Log Private M.S. 13.46, subd. 119 Catie Lee

Vulnerable Adult Investigation Checklist Private M.S. 13.46, subd. 120 Catie Lee

Notice of Privacy Practice Private M.S. 13.46, subd. 121 Catie Lee

Intake Interview Guide – Client Private M.S. 13.46, subd. 122 Catie Lee

Intake Interview Guide - Collateral Private M.S. 13.46, subd. 123 Catie Lee

Assessment Tool Private M.S. 13.46, subd. 124 Catie Lee

Mini Mental Status Exam Private M.S. 13.46, subd. 125 Catie Lee

Geriatric Depression Scale Private M.S. 13.46, subd. 126 Catie Lee

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Social Services

Checklist Helps to Tell How The Person Is Doing Private M.S. 13.46, subd. 127 Catie Lee

Hoarding Assessment Tool Private M.S. 13.46, subd. 128 Catie Lee

Vulnerable Adult Investigative Summary Private M.S. 13.46, subd. 129 Catie LeeLONG TERM CARE FORMSDHS-5181 Communication Form Private M.S. 13.46, subd. 130 Catie Lee

LTCC Supplemental Form Private M.S. 13.46, subd. 131 Catie Lee

LTCC Intake Form Private M.S. 13.46, subd. 132 Catie Lee

Case Management Assessment Private M.S. 13.46, subd. 133 Catie Lee

DHS-3543 Request for Payment for LTC Services Private M.S. 13.46, subd. 134 Catie Lee

Customized Living Tool (online) Private M.S. 13.46, subd. 135 Catie Lee

Under 65 in NH waiver Form Private M.S. 13.46, subd. 136 Catie Lee

EW Cap Increase Request Private M.S. 13.46, subd. 137 Catie Lee

DHS-3426 Level I Private M.S. 13.46, subd. 138 Catie Lee

DHS-3457 Level II – MI Private M.S. 13.46, subd. 139 Catie Lee

DHS-4248 Level II – DD Private M.S. 13.46, subd. 140 Catie Lee

Initial Checklist Private M.S. 13.46, subd. 141 Catie Lee

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Reassessment Checklist Private M.S. 13.46, subd. 142 Catie Lee

Notice to Physician of LTCC Consultation Private M.S. 13.46, subd. 143 Catie Lee

DHS-3427 LTC Screening Document Private M.S. 13.46, subd. 144 Catie Lee

DHS-2727 Application for HCBS/Information Sheet Private M.S. 13.46, subd. 145 Catie Lee

DHS-3428 LTCC Assessment Form Private M.S. 13.46, subd. 146 Catie Lee

DHS-3428B Case Mix Worksheet Private M.S. 13.46, subd. 147 Catie Lee

DHS-2925 LTCC Community Support Plan Private M.S. 13.46, subd. 148 Catie Lee

DHS-3340 Asset Assessment for Medical Assistance Private M.S. 13.46, subd. 149 Catie Lee

DHS-2630 AC Eligibility Worksheet Private M.S. 13.46, subd. 150 Catie Lee

DHS-2630 AC Eligibility Worksheet (for married person w/comm spouse) Private M.S. 13.46, subd. 151 Catie Lee

DHS-3548 AC Client disclosure Form Private M.S. 13.46, subd. 152 Catie Lee

DHS-4801 AC Estate Claim Referral Worksheet Private M.S. 13.46, subd. 153 Catie Lee

CCBI Initial Screening Checklist Private M.S. 13.46, subd. 154 Catie Lee

CCBI Reassessment Checklist Private M.S. 13.46, subd. 155 Catie Lee

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Medical Reports/Certs-485 Private M.S. 13.46, subd. 156 Catie Lee

Provider Reports Private M.S. 13.46, subd. 157 Catie Lee

Risk Management Plans Private M.S. 13.46, subd. 158 Catie Lee

Guardianship Orders Private M.S. 13.46, subd. 159 Catie Lee

Advanced Directives Private M.S. 13.46, subd. 160 Catie Lee

CCBI Waiver Management System Reports (online) Private M.S. 13.46, subd. 161 Catie Lee

Amended Service Plan Private M.S. 13.46, subd. 162 Catie Lee

Individual Waiver Budget Review Private M.S. 13.46, subd. 163 Catie Lee

Disability waivers Rate Management Tool (online) Private M.S. 13.46, subd. 164 Catie Lee

MCO Form Enrollment Reports Private M.S. 13.46, subd. 165 Catie Lee

MCO Form Notification of Care Coordinator Assigned Private M.S. 13.46, subd. 166 Catie Lee

MCO Form Transition Logs Private M.S. 13.46, subd. 167 Catie Lee

MCO Form ICF/DD & HCBS Disability Waiver HRA & Care Plan Supplement Private M.S. 13.46, subd. 168 Catie Lee

MCO Form Collaborative Care Plan Private M.S. 13.46, subd. 169 Catie Lee

MCO Form Health Risk Assessment Private M.S. 13.46, subd. 170 Catie Lee

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Social Services

MCO Form Recommendations for State Plan Home Care Services Private M.S. 13.46, subd. 171 Catie Lee

MCO Form MA Home Care Services Recommendations – non-disabled Private M.S. 13.46, subd. 172 Catie Lee

MCO Form Notification of Potential DT&R Private M.S. 13.46, subd. 173 Catie Lee

MCO Form Elderly Waiver Prior Authorization Request Private M.S. 13.46, subd. 174 Catie Lee

MCO Form Notification of Member Change Private M.S. 13.46, subd. 175 Catie Lee

DHS-0029 Income Computation Worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-0033 Appeal to State Agency Private M.S. 13.46, subd 2 Catie Lee

DHS-0035 State Agency Appeals Summary Private M.S. 13.46, subd 2 Catie Lee

DHS-1503 Level of Care Statement Private M.S. 13.46, subd 2 Catie Lee

DHS-1609 Nonreceipt/replacement affidavit Private M.S. 13.46, subd 2 Catie Lee

DHS-1795 SSI interim asst. authorization agreement Private M.S. 13.46, subd 2 Catie Lee

DHS-1795A Interim asst. agreement Private M.S. 13.46, subd 2 Catie Lee

DHS-1829 MA Spenddown Worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-1844 Medical Expenses Private M.S. 13.46, subd 2 Catie Lee

DHS-1922B MN Health Care Program Health Insurance Information Private M.S. 13.46, subd 2 Catie Lee

DHS-1958 Full Child Support Services Application Private M.S. 13.46, subd 2 Catie Lee

Name of Form, Record, File,

System, or Process







Swift County Responsible Authority - Catie Lee


Income Maintenance Unit

DHS-2114 Request for medical opinion Private M.S. 13.46, subd 2 Catie Lee

DHS-2116 Notice to apply for other maintenance benefits Private M.S. 13.46, subd 2 Catie Lee

DHS-2120 Household report form Private M.S. 13.46, subd 2 Catie Lee

DHS-2128 MA long-term care ER Private M.S. 13.46, subd 2 Catie Lee

DHS-2136 Claim Determination Form Private M.S. 13.46, subd 2 Catie Lee

DHS-2146 Consent for Release of Employment Information Private M.S. 13.46, subd 2 Catie Lee

DHS-2237 Medical Service Questionnaire Private M.S. 13.46, subd 2 Catie Lee

DHS-2338 Cooperation with Child Support Enforcement Private M.S. 13.46, subd 2 Catie Lee

DHS-2243 Authorization for release of information about assets Private M.S. 13.46, subd 2 Catie Lee

DHS-2243A General consent for release of information Private M.S. 13.46, subd 2 Catie Lee

DHS-2286 Tips Report Form Private M.S. 13.46, subd 2 Catie Lee

DHS-2338 Client Statement of good Cause Private M.S. 13.46, subd 2 Catie Lee

DHS-2402 Change Report Form Private M.S. 13.46, subd 2 Catie Lee

DHS-2414 Notice of late or Incomplete Household Report Form Private M.S. 13.46,subd 2 Catie Lee

DHS-2646 Financial aid information form Private M.S. 13.46, subd 2 Catie Lee

DHS-2686A Child Support Enforement Notification Private M.S. 13.46, subd 2 Catie Lee

DHS-2402 Change report form Private M.S. 13.46, subd 2 Catie Lee

DHS-2414 Household report form renewal Private M.S. 13.46, subd 2 Catie Lee

DHS-2775 Notice of Overpayment Private M.S. 13.46, subd 2 Catie Lee

DHS-2776 Diversionary Work Program and Work Benefit Private M.S. 13.46, subd 2 Catie LeeOverpayment Worksheet

DHS-2841 Cost Effective Insurance Forms Private M.S. 13.46, subd 2 Catie Lee

DHS-2882 Referral of Minor Parent to Social Services Private M.S. 13.46, subd 2 Catie Lee

DHS-2883 Request for Verification of School Attendance Private M.S. 13.46, subd 2 Catie Lee

DHS-2919A Verification request Form A Private M.S. 13.46, subd 2 Catie Lee

DHS-2919B Verification request Form B Private M.S. 13.46, subd 2 Catie Lee

DHS-2952 Residence shelter and expense Private M.S. 13.46, subd 2 Catie Lee

DHS-2961 Notice of Requirement to Attend School Private M.S. 13.46, subd 2 Catie Lee

DHS 2975 Transition Year Medical Assistance Quarterly Report Private M.S. 13.46, subd 2 Catie Lee

DHS-2984 Request for voluntary vendor payment Private M.S. 13.46, subd 2 Catie Lee

DHS-3050 MHCP Long Term Care/County Communication Form Private M.S. 13.46, subd 2 Catie Lee

DHS-3131 Notice of Intentional Program Violation Private M.S. 13.46, subd 2 Catie LeeWaiver of Administrative Disqualification

DHS-3132 Hearing Request of Administrative Disq. Hearing Private M.S. 13.46, subd 2 Catie Lee

DHS-3134 Notice of Program Violations Private M.S. 13.46, subd 2 Catie Lee

DHS-3159 Recognition of Parentage Private M.S. 13.46, subd 2 Catie Lee

DHS-3159b MN Voluntary Recognition of Parentage Revocation Private M.S. 13.46, subd 2 Catie Lee

DHS-3159c MN Voluntary Recognition of Parentage Husband's Private M.S. 13.46, subd 2 Catie LeeNon-Paternity Statement

DHS-3161 Request for Designated Provider Agreement Private M.S. 13.46, subd 2 Catie Lee

DHS-3163B Referral to support and collections Private M.S. 13.46, subd 2 Catie Lee

DHS-3164 Income Withholding-Only Services Application Private M.S. 13.46, subd 2 Catie Lee

DHS-3165 DWP/MFIP Status Update Form Private M.S. 13.46, subd 2 Catie Lee

DHS-3166 Employment Services Referral Private M.S. 13.46, subd 2 Catie Lee

DHS-3175 MFIP Notice of Intent to Sanction Private M.S. 13.46, subd 2 Catie Lee

DHS-3195 Inter-Agency Case Transfer Sheet Private M.S. 13.46, subd 2 Catie Lee

DHS-3203 MA Lien Worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-3236 Pregnancy verification form Private M.S. 13.46, subd 2 Catie Lee

DHS-3271 MN Health Care Programs Request for Information Private M.S. 13.46, subd 2 Catie Lee

DHS-3328 MHCP Request for Social Security Number Private M.S. 13.46, subd 2 Catie Lee

DHS-3335 Fraud Prevention Investigation Referrals Private M.S. 13.46, subd 2 Catie Lee

DHS-3336 Self-employment report form Private M.S. 13.46, subd 2 Catie Lee

DHS-3337 Self-Employment Worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-3340 Asset Assessment Private M.S. 13.46, subd 2 Catie Lee

DHS-3341 Asset Reduction Worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-3348 MHCP Employer Insurance Information Form Private M.S. 13.46, subd 2 Catie Lee

DHS-3358 Application transfer Private M.S. 13.46, subd 2 Catie Lee

DHS-3365 Mandatory Vendor Form-Request for Information Private M.S. 13.46, subd 2 Catie Lee

DHS-3371 Direct Deposit for Child Support Private M.S. 13.46, subd 2 Catie Lee

DHS-3417 MN health care application Private M.S. 13.46, subd 2 Catie Lee

DHS-3418 MN health care programs renewal form Private M.S. 13.46, subd 2 Catie Lee

DHS-3429 Disqualification Consent Form Private M.S. 13.46, subd 2 Catie Lee

DHS-3437 Giving Permission for Someone to Act on their Behalf Private M.S. 13.46, subd 2 Catie Lee

DHS-3439 MHCP Medicare Buy-In Referral Letter Private M.S. 13.46 subd 2 Catie Lee

DHS-3441 Health Care Income/Asset Renewal Private M.S. 13.46,subd 2 Catie Lee

DHS-3444 MHCP Medicare Application Referral Letter Private M.S. 13.46, subd 2 Catie Lee

DHS-3525 MN MA App/Renewal Breast & Cervical Cancer Private M.S. 13.46, subd 2 Catie Lee

DHS-3525A MHCP Certification of Further Treatment Required Private M.S. 13.46, subd 2 Catie Lee

DHS-3531 MN HCAP for seniors and people with disabilities Private M.S. 13.46, subd 2 Catie Lee

DHS-3543 Request for Payment of Long Term Care Services Private M.S. 13.46, subd 2 Catie Lee

DHS-3547 MA for Employed Persons with Disabilities Initial Private M.S. 13.46, subd 2 Catie LeePremium Notice

DHS-3550 Child Care Application Private M.S. 13.46, subd 2 Catie Lee

DHS-3727 Combined Application Renewal for Certain Populations Private M.S. 13.46, subd 2 Catie Lee

DHS-4003 Child Care Transmittal Private M.S. 13.46, subd 2 Catie Lee

DHS-4060 Request to Close Support Case Private M.S. 13.46, subd 2 Catie Lee

DHS-4106A Health plan enrollment form Private M.S. 13.46, subd 2 Catie Lee

DHS-4117 Automatic Withdrawl for Your Child Support Private M.S. 13.46, subd 2 Catie Lee

DHS-4145 County Notice of IMD Resident Status Private M.S. 13.46, subd 2 Catie Lee

DHS-4209 Employment Plans Private M.S. 13.46, subd 2 Catie Lee

DHS-4533 Stored Value Card Private M.S. 13.46, subd 2 Catie Lee

DHS-4583 Request for Exception to Direct Deposit Private M.S. 13.46, subd 2 Catie Lee

DHS-4600 MHCP Notice of Medical Assistance Overpayment Private M.S. 13.46, subd 2 Catie Lee

DHS-4602 Absent Day Medical Exemption Form Private M.S. 13.46, subd 2 Catie Lee

DHS-4794 Child care asst. program - change report form Private M.S. 13.46, subd 2 Catie Lee

DHS-4796 Health Care Change Report Form Private M.S. 13.46, subd 2 Catie Lee

DHS-4841 MHCP Authorization to Request Birth Records Private M.S. 13.46, subd 2 Catie Lee

DHS-4915 Medical Assistance Payment of Long Terma Care Ser Private M.S. 13.46, subd 2 Catie Lee

DHS-4931 Unreimbursed and/or Uninsured Medical Dental Private M.S. 13.46, subd 2 Catie LeeExpenses Packet

DHS-4933 Hardship Waiver Private M.S. 13.46, subd 2 Catie Lee

DHS-4939 Notice of Medical Assistance Overpayment Private M.S. 13.46, subd 2 Catie Lee

DHS-5143 MHCP Required Annuity Information Private M.S. 13.46, subd 2 Catie Lee

DHS-5181 Lead Agency/Case Manager/Communication Form Private M.S. 13.46, subd 2 Catie Lee

DHS-5203 Request for Income Verification Private M.S. 13.46, subd 2 Catie Lee

DHS-5223 Combined application form Private M.S. 13.46, subd 2 Catie Lee

DHS-5223B Minnesota Family Investiment Program Transition Private M.S. 13.46, subd 2 Catie LeeApplication

DHS-5223C Combined application form addendum Private M.S. 13.46, subd 2 Catie Lee

DHS-5223D Child Care Addendum to Combined Application Private M.S. 13.46, subd 2 Catie Lee

DHS-5274 Child care asst. program redetermination form Private M.S. 13.46, subd 2 Catie Lee

DHS-5367 Parent Acknowledgment for Legal Non-Licensed Private M.S. 13.46, subd 2 Catie LeeProvider

DHS-5426 Long Term Care Partnership Ins Policy Evaluation Private M.S. 13.46, subd 2 Catie Lee

DHS-5510 Authorization for Release of Child support Information Private M.S. 13.46, subd 2 Catie Leeto a Third Party

DHS-5576 Combined six-month report Private M.S. 13.46, subd 2 Catie Lee

DHS-5590 Long Term Care Checklist Private M.S. 13.46, subd 2 Catie Lee

DHS-5785 Income Withholding for Spousal Support Private M.S. 13.46, sudb 2 Catie Lee

DHS-6123 Referral for disability determination Private M.S. 13.46, subd 2 Catie Lee

DHS-6124 Authorization to disclose info. for disability determ. Private M.S. 13.46, subd 2 Catie Lee

DHS-6126 Children's disability worksheet Private M.S. 13.46, subd 2 Catie Lee

DHS-6523 Financial Statement Private M.S. 13.46, subd 2 Catie Lee

DHS-6696 MNSure Application Form Private M.S. 13.46, subd 2 Catie Lee

F0003 Establishment Order Private M.S. 13.46, subd 2 Catie Lee

F0008 Paternity Order Private M.S. 13.46, subd 2 Catie Lee

F0009 Admission of Service Private M.S. 13.46, subd 2 Catie Lee

F0016 Affidavit of Service by Mail Private M.S. 13.46, subd 2 Catie Lee

F0021 Financial Statement Private M.S. 13.46, subd 2 Catie Lee

F0022 Important Statement of Rights Private M.S. 13.46, subd 2 Catie Lee

F0029 Establishment Summons (no hearing date) Private M.S. 13.46, subd 2 Catie Lee

F0038 Modification Order Private M.S. 13.46, subd 2 Catie Lee

F0039 Affidavit of Default/Expedited Process Private M.S. 13.46, subd 2 Catie Lee

F0042 Establishment Complaint Private M.S. 13.46, subd 2 Catie Lee

F0061 Paternity Summons Private M.S. 13.46, subd 2 Catie Lee

F0067 Consent, Oath & Order Appointing Guardian Private M.S. 13.46, subd 2 Catie Lee

F0074 Motion for Order Appointment a Guardian Private M.S. 13.46, subd 2 Catie Lee

F0076 Motion to Dismiss Private M.S. 13.46, subd 2 Catie Lee

F0082 Dismissal Order Private M.S. 13.46, subd 2 Catie Lee

F0083 Paternity Complaint Private M.S. 13.46, subd 2 Catie Lee

F0090 Motion to Set Order Private M.S. 13.46, subd 2 Catie Lee

F0091 Notice & Acknowledgement of Service Private M.S. 13.46, subd 2 Catie Lee

F0093 Motion to Establish Support Private M.S. 13.46, subd 2 Catie Lee

F0095 Certificate of Representation Private M.S. 13.46, subd 2 Catie Lee

F0096 Motion for Modication Private M.S. 13.46, subd 2 Catie Lee

F0100 Authorization to Collect Support Private M.S. 13.46, subd 2 Catie Lee

F0101 Change in Maintaining County Notice Sent Private M.S. 13.46, subd 2 Catie Lee

F0102 Change in Maintaining County Notice Private M.S. 13.46, subd 2 Catie Lee

F0104 Memo Document Private M.S. 13.46, subd 2 Catie Lee

F0107 Notification of Medical Support Liability Private M.S. 13.46, subd 2 Catie Lee

F0108 Notice of Child support/Spousal Maintenance Private M.S. 13.46, subd 2 Catie Lee

F0109 Notification of Parental Liability for Support Private M.S. 13.46, subd 2 Catie Lee

F0112 Notice of Payment Redirection Private M.S. 13.46, subd 2 Catie Lee

F0113 Authorization to Collect Support Arrears Private M.S. 13.46, subd 2 Catie Lee

F0114 Memo Financial Catie Lee

F0116 Notice of Excess Support Private M.S. 13.46, subd 2 Catie Lee

F0118 Notice fo Federal Annual Fee Private M.S. 13.46, subd 2 Catie Lee

F0125 Information on Cost Recovery Fee Private M.S. 13.46, subd 2 Catie Lee

F0126 Information on Cost Recovery Fee NCP Private M.S. 13.46, subd 2 Catie Lee

F0170 Notice of Assignment of Support to Court Private M.S. 13.46, subd 2 Catie Lee

F0300 Emancipation Notice to CP Private M.S. 13.46, subd 2 Catie Lee

F0302 Emancipation Notice to NCP Private M.S. 13.46, subd 2 Catie Lee

F0306 EMAN Follow-Up Proof of Enrollment Request Private M.S. 13.46, subd 2 Catie Lee

F0500 NCP Redirection Notice Private M.S. 13.46, subd 2 Catie Lee

F0502 Caregiver Redirection Notice Private M.S. 13.46, subd 2 Catie Lee

F0503 NCP Redirection Stop Notice Private M.S. 13.46, subd 2 Catie Lee

F0505 Caregiver Redirection Stop Notice Private M.S. 13.46, subd 2 Catie Lee

F0506 Caregiver Notice - Court Decided No ReDirect Private M.S. 13.46, subd 2 Catie Lee

F0524 CP Notice of Genetic Test Results Private M.S. 13.46, subd 2 Catie Lee

F0525 NCP Notice of Genetic Test Results Private M.S. 13.46, subd 2 Catie Lee

F0607 Ex Parte Motion of Nondisclosure Order Private M.S. 13.46, subd 2 Catie Lee

F0609 Certificate of Service Private M.S. 13.46, subd 2 Catie Lee

F0610 Important Information - Acknowledgement Private M.S. 13.46, subd 2 Catie Lee

F0611 Affidavit of Personal Service Private M.S. 13.46, subd 2 Catie Lee

F0616 Cancel Hearing Notice Private M.S. 13.46, subd 2 Catie Lee

F0633 Affidavit of Default & ID - conditional Private M.S. 13.46, subd 2 Catie Lee

F0641 Affidavit of Identification Private M.S. 13.46, subd 2 Catie Lee

F0642 Full Satifaction of Judgement Private M.S. 13.46, subd 2 Catie Lee

F0645 Certified Judgement Satisfaction Request Private M.S. 13.46, subd 2 Catie Lee

F0661 Failure to Notify Public Authority Notice Private M.S. 13.46, subd 2 Catie Lee

F0663 Affidavit of Service by FAX Private M.S. 13.46, subd 2 Catie Lee

F0665 Hearing Reminder Notice Private M.S. 13.46, subd 2 Catie Lee

F0675 Request for Writ of Attachment Private M.S. 13.46, subd 2 Catie Lee

F0676 Order for Writ of Attachment & Writ of Attachment Private M.S. 13.46, subd 2 Catie Lee

F0679 Affidavit of Noncompliance Private M.S. 13.46, subd 2 Catie Lee

F0681 Motion for Contempt Private M.S. 13.46, subd 2 Catie Lee

F0682 Supporting Affidavit - Contempt Private M.S. 13.46, subd 2 Catie Lee

F0685 Contempt Agreement Private M.S. 13.46, subd 2 Catie Lee

F0688 Contempt Order to Show Cause Private M.S. 13.46, subd 2 Catie Lee

F0689 Contempt Order Private M.S. 13.46, subd 2 Catie Lee

F0927 Health/Dental Insurance Verification Request Private M.S. 13.46, subd 2 Catie Lee

F0929 Notice of Private Health Insurance Obligation Private M.S. 13.46, subd 2 Catie Lee

F0932 Cover Letter for F0930 - Medical Payment Private M.S. 13.46, subd 2 Catie Lee

F0999 Pin Notice Private M.S. 13.46, subd 2 Catie Lee

F1001 Warrant Replacement Request Private M.S. 13.46, subd 2 Catie Lee

F1002 Affidavit of Lost or Stolen Warrant Private M.S. 13.46, subd 2 Catie Lee

F1012 Notice of Direct Payment Recovery Private M.S. 13.46, subd 2 Catie Lee

F1013 Direct Payment Notice to CP Private M.S. 13.46, subd 2 Catie Lee

F1014 Direct Pyament Notice to NCP Private M.S. 13.46, subd 2 Catie Lee

F1018 Notice of Overpayment Recovery -Custodial Parent Private M.S. 13.46, subd 2 Catie Lee

F1019 Notice of Overpayment Recovery - NCP Private M.S. 13.46, subd 2 Catie Lee

F1023 Notice of Misapplied Funds Private M.S. 13.46, subd 2 Catie Lee

F1024 Notice of Misapplied Funds Sent Private M.S. 13.46, subd 2 Catie Lee

F1031 Notice of Payment Adjustment Private M.S. 13.46, subd 2 Catie Lee

F1032 Notice of State Tax Adjustment Private M.S. 13.46, subd 2 Catie Lee

F1042 Notice of Payment Summary & Account ST Private M.S. 13.46, subd 2 Catie Lee

F1111 Confidential Information Form Private M.S. 13.46, subd 2 Catie Lee

F1118 Notice of Medical Expenses Recovery-Custodial Parent Private M.S. 13.46, subd 2 Catie Lee

F1119 Notice of Medical Expenses Recovery -Non-cusotdial Private M.S. 13.46, subd 2 Catie Lee

F1159 Notice of Obligor's Request to Close Case Private M.S. 13.46, subd 2 Catie Lee

F1160 Notice of Intent to Close Case Private M.S. 13.46, subd 2 Catie Lee

F1161 Notice of Change in Service for Interstate SMO Private M.S. 13.46, subd 2 Catie Lee

F1163 Notice of Case Closure SMO - NCP MN Resp Private M.S. 13.46, subd 2 Catie Lee

F1164 Final Notice of Intent to Close Case Private M.S. 13.46, subd 2 Catie Lee

F1165 Notice of Intent to Close NPA Case -PAR Private M.S. 13.46, subd 2 Catie Lee

F1166 Notice of Change in Services for SMO CAS Private M.S. 13.46, subd 2 Catie Lee

F1168 Notice to CP of Pending SMO Case Closure Private M.S. 13.46, subd 2 Catie Lee

F1169 Notice to NCP of Pending SMO Case Closure Private M.S. 13.46, subd 2 Catie Lee

F1171 Notice to Other State of Pending SMO Case Closure Private M.S. 13.46, subd 2 Catie Lee

F1173 Notice of Case Closure (Responding State) Private M.S. 13.46, subd 2 Catie Lee

F1174 Notice of Case Closure (Initiating State) Private M.S. 13.46, subd 2 Catie Lee

F1177 Notice of Change in SMO Law - CP Private M.S. 13.46, subd 2 Catie Lee

F1178 Notice of Change in SMO Law - NCP Private M.S. 13.46, subd 2 Catie Lee

F1179 Notice of Change in SMO Law - CP closed Private M.S. 13.46, subd 2 Catie Lee

F2598 Support Affidavit for Controlling Order Private M.S. 13.46, subd 2 Catie Lee

F2599 Motion for Controlling Order Private M.S. 13.46, subd 2 Catie Lee

F2600 Controlling Order Private M.S. 13.46, subd 2 Catie Lee

F5002 Supporting Affidavit - Establishment Private M.S. 13.46, subd 2 Catie Lee

F5003 RC/FC Establishment Complaint (w/option motion) Private M.S. 13.46, subd 2 Catie Lee

F5007 Supporting Affidavit - Paternity Private M.S. 13.46, subd 2 Catie Lee

F5008 RC/FC Support Affidavit - Motion to Set Private M.S. 13.46, subd 2 Catie Lee

F5013 Support Affidavit - RC/FC Establishment Private M.S. 13.46, subd 2 Catie Lee

F5023 RC/FC Establishment Order Private M.S. 13.46, subd 2 Catie Lee

F5029 Establishment summons Including Hearing Date Private M.S. 13.46, subd 2 Catie Lee

F5037 Support Affidavit - Review/Modification Private M.S. 13.46, subd 2 Catie Lee

F5040 RC/FC Motion for Establishment Private M.S. 13.46, subd 2 Catie Lee

F5041 RC/FC Motion with Hearing Date Private M.S. 13.46, subd 2 Catie Lee

F5050 RC/FC Establishment Order Private M.S. 13.46, subd 2 Catie Lee

F5088 Support Affidavit - Motion to Set Private M.S. 13.46, subd 2 Catie Lee

F5093 Motion (with hearing date) to Establish Support Private M.S. 13.46, subd 2 Catie Lee

F5096 Motion (with hearing date) to Modify Support Private M.S. 13.46, subd 2 Catie Lee

F5105 Contested Levy Results Private M.S. 13.46, subd 2 Catie Lee

F5152 Payment Affidavit Private M.S. 13.46, subd 2 Catie Lee

F5800 RC/FC Motion for Modification (no hearing date) Private M.S. 13.46, subd 2 Catie Lee

F5801 RC/FC Support Affidavit - Modification Private M.S. 13.46, subd 2 Catie Lee

F5802 RC/FC Modification Order Private M.S. 13.46, subd 2 Catie Lee

F6001 Monthly Expense Statement Private M.S. 13.46, subd 2 Catie Lee

F6500 Request for Child Care Support Verification Private M.S. 13.46, subd 2 Catie Lee

F6501 Notice fo Child Care Support Continuing Private M.S. 13.46, subd 2 Catie Lee

F6502 Notice of Child Care Support Suspending Private M.S. 13.46, subd 2 Catie Lee

F6503 Notices of Child Care Support Resuming Private M.S. 13.46, subd 2 Catie Lee

F6504 Non-Custodial Parent Case Summary Private M.S. 13.46, subd 2 Catie Lee

F6519 Notice of Interest Suspension Eligibility Private M.S. 13.46, subd 2 Catie Lee

F6522 Notice of Denial of Suspension of INTERE Private M.S. 13.46, subd 2 Catie Lee

F6523 Notice of Resumption of Interest Charging Private M.S. 13.46, subd 2 Catie Lee

F9000 Child Support Guidelines Worksheet Private M.S. 13.46, subd 2 Catie Lee

F9850 Notice of Arrears Management Action Private M.S. 13.46, subd 2 Catie Lee

F9945 Notice of Mandatory DD of Support Private M.S. 13.46, subd 2 Catie Lee

P&I Administrative Vouchers Private M.S. 13.46, subd 2 Catie Lee

P&I SSIS Vouchers Private M.S. 13.46, subd 2 Catie Lee

P&I MEC2 Vouchers Private M.S. 13.46, subd 2 Catie Lee

P&I SSIS Service Arrangements Private M.S. 13.46, subd 2 Catie Lee

P&I Revenue Recapture Statements Private M.S. 13.46, subd 2 Catie Lee

P MA Access/Cost Effective Statements Private M.S. 13.46, subd 2 Catie Lee

P&I SWF Billing Forms Private M.S. 13.46, subd 2 Catie Lee

P MN-ITS Claiming Forms Private M.S. 13.46, subd 2 Catie Lee

P&I Warrant Registers Private M.S. 13.46, subd 2 Catie Lee

P Determination of Fees Private M.S. 13.46, subd 2 Catie Lee

P Adoption Registry Private M.S. 13.46, subd 2 Catie Lee

P&I Board Data Entry Lists Private M.S. 13.46, subd 2 Catie Lee

Name of Form, Record, File, System, or

Process







Swift County Responsible Authority - Catie Lee



P Receipts Private M.S. 13.46, subd 2 Catie Lee

P Screening Delection Forms (Waiver) Private M.S. 13.46, subd 2 Catie Lee

P Service Agreeement Forms (Waiver) Private M.S. 13.46, subd 2 Catie Lee

P IV-E Routing Slips Private M.S. 13.46, subd 2 Catie Lee

P Placement Record Forms Private M.S. 13.46, subd 2 Catie Lee

P SSIS Purge Report Private M.S. 13.46, subd 2 Catie Lee

DHS5190 MEC2 License Provider Registration Private M.S. 13.46, subd 2 Catie Lee

DHS3552 MEC2 Direct Deposit Registration Private M.S. 13.46, subd 2 Catie Lee

MEC2 Child Care Log Private M.S. 13.46, subd 2 Catie Lee

DHS5192 MEC2 Legal Nonlicensed Provider Registration Private M.S. 13.46, subd 2 Catie Lee

DHS5193 MEC2 CC Asst Authorization for Background Study Private M.S. 13.46, subd 2 Catie Lee

DHS2570 Title IV-E Report Private M.S. 13.46, subd 2 Catie Lee

DHS3150.2 TCM CSR Report Private M.S. 13.46,subd 2 Catie Lee

DHS Relative Custody Assistance Report Private M.S. 13.46, subd 2 Catie Lee

SCHS7200 Child Care Budget Report Private M.S. 13.46, subd 2 Catie Lee

SCHS5350 DD Family Subsidy Budget Report Private M.S. 13.46, subd 2 Catie Lee

SCHS5340 DD SILS Budget Report Private M.S. 13.46, subd 2 Catie Lee

SCHS6230 Chore Services Budget Report Private M.S. 13.46, subd 2 Catie Lee

SCHS5380 Supported Employment Budget Report Private M.S. 13.46, subd 2 Catie Lee

SCHS5660 DT&H Budget Report Private M.S. 13.46, subd 2 Catie Lee

W-9 Request for Taxpayer ID# Private M.S. 13.46, subd 2 Catie Lee

File Destruction List Private M.S. 13.46, subd 2 Catie Lee

Transportation Form Used to send requests to transportation vendor for rides Private M.S. 13.46, subd 2 Catie Lee, Director

Burial Application Used to determine eligibility for county burial Private M.S. 13.46, subd 2 Catie Lee, Director

Reimbursement Adjustment

Used to inform client of reimbursement adjustment Private M.S. 13.46, subd 2 Catie Lee, Director

Notice to Child Support

Used to notify open/close/change in public programs from IV-A to IV-D

Private M.S. 13.46, subd 2 Catie Lee, Director

Applicaton Cover Sheet

Used to inform client about appointment requirement Private M.S. 13.46, subd 2 Catie Lee, Director

Request Closing of Public Programs

Used by client to request their case closed Private M.S. 13.46, subd 2 Catie Lee, Director

ProgramsEmployer Verification Used to verify wages for clients Private M.S. 13.46, subd 2 Catie Lee, Director

Employment Verification for

Used to verify employment and work schedules Private M.S. 13.46, subd 2 Catie Lee, Director

CCAPRequest for Health Ins Used to pay out reimburse to client Private M.S. 13.46, subd 2 Catie Lee, Director

Name of Form,

Record, File, System, or

Process

Description(Purpose, what it collects, in terms understandable by general public)

Classification

Citation for Classification(Statute, Law,

or Rule)Designee

(Name, Title)



Swift County

Responsible Authority - Catie Lee Community Social Services Director


Premium ReimbursementRequest for Mileage Used for clients to get reimbursed for travel to medical Private M.S. 13.46, subd 2 Catie Lee, Director

Reimbursement appointmentsCounty Crisis Application

Clients use to apply for County Crisis Funds Private M.S. 13.46, subd 2 Catie Lee, Director

Demand for Notice Sent to Court to report when client's probate is started Private M.S. 13.46, subd 2 Catie Lee, Director

Time of Death Fact Sheet

Used to report assets client has at time of death Private M.S. 13.46, subd 2 Catie Lee, Director

Waiver of MA Claim Used for families to apply for hardship waiver Private M.S. 13.46, subd 2 Catie Lee, Director

Certificate of Clearance

Given to court to verify we have no outstanding medical claims against a client


Worksheet for Co Crisis

Used by EW to determine eligibility for Cty Crisis Funds Private M.S. 13.46, subd 2 Catie Lee, Director

Affidavit of Service by Mail

Used to verify when we send mail to client on a claim Private M.S. 13.46, subd 2 Catie Lee, Director

In-House Ma Recoveries

Used to give accounting information on MA recovery Private M.S. 13.46, subd 2 Catie Lee, Director

FEMA Rent & Mortgage

Used to verify emergency payment of rent or mortgage Private M.S. 13.46, subd 2 Catie Lee, Director

FEMA Metered Utility Used to verify emergency payment of a utility Private M.S. 13.46, subd 2 Catie Lee, Director

Transition Year MA Worksheet to track eligibility for TYMA Private M.S. 13.46, subd 2 Catie Lee, Director

SMRT Referral to clerical

Used to provide information on disability to be faxed to Private M.S. 13.46, subd 2 Catie Lee, Director

State Medical Review Team by clerical

Notice of Health Care Access

Gives client's information on access serivces and Private M.S. 13.46, subd 2 Catie Lee, Director

Services to client resources available in the countyNotice to Applicant Used by child support to determine level of services that

client wants when applying for MAPrivate M.S. 13.46, subd 2 Catie Lee, Director

Background check form for

Used to gather information on background checks for Private M.S. 13.46, subd 2 Catie Lee, Director

Child Care Program legal non-licensed providers

Request for medical Info Used with job search counselor to gather information on abi


Direct Deposit Request

Used for clients to request direct deposit of cash assistance Private M.S. 13.46, subd 2 Catie Lee, Director

Good Cause Exemption


Good Cause Decision Used to inform client of good cause claim Private M.S. 13.46, subd 2 Catie Lee, Director

Employment Search Used by Child Support Officer to verify job search for Private M.S. 13.46, subd 2 Catie Lee, Director

Verification clientMFIP Orientation Checklist

Used by Elig Worker with client to orientate to MFIP Prog Private M.S. 13.46, subd 2 Catie Lee, Director

MFIP Waiver/child under 1

Used by client to request exemption from work due to child under 1


New Vendor Info Request

Used to gather information on vendor Private M.S. 13.46, subd 2 Catie Lee, Director

Child Care School Grant

Used to verify if someone attending school is eligible for a child care grant


Child Care Job Search Used to document client's job search for child care eligibility


CC Occupational Research

Used to document school program for Child Care eligibility while attending school


Child Care Assistance Provider form

Used to gather Info on provider for Child Care Private M.S. 13.46, subd 2 Catie Lee, Director

Basic Sliding Fee Waiting

Tracks request for day care when funds have been used Private M.S. 13.46, subd 2 Catie Lee, Director

ListTransition Year Waiting List

Tracks request for day care when Basic Sliding Fee has a waiting list


Portability Waiting List

Tracks clients who move into the county and are eligible Private M.S. 13.46, subd 2 Catie Lee, Director

for day care and we have a waiting listChild Care App Cover Letter

Informs clients of the application process Private M.S. 13.46, subd 2 Catie Lee, Director

Social Service Referral Used to provide information to Social Services on a Private M.S. 13.46, subd 2 Catie Lee, Director

clientSpecial Diet Information

Used to gather doctor verification of prescribed diet Private M.S. 13.46, subd 2 Catie Lee, Director

Overpayment of Child Care

Used to document overpayment in the child care Private M.S. 13.46, subd 2 Catie Lee, Director

Assistance systemCard with HH information

Quick reference guide with numbers for client and family members along with case numbers


TANF Monthly Tracking Rpt

Used to track used months of TANF recipients Private M.S. 13.46, subd 2 Catie Lee, Director

Documents

Page 1 of 95 MINNESOTA GOVERNMENT DATA PRACTICES ACT · Page 1 of 95 This document is a public record pursuant to Minnesota Statute 13.05 2/1/2018 70001-1 Completed fee cover sheet