Forms List
Links to forms used in this course are found below and on pages throughout the course at the time a form is referenced. Although you are not required to print these forms, you will need them available as you take the course. You may choose to gather the forms from your county forms supply, or print them from eDocs using the following links.
DHS-3271 MHCP Request for Information (PDF).
DHS-3050 LTC/County Communication Form (PDF).
DHS-4915 Notice of Action for Payment of LTC Services (PDF).
DHS-5036 Annuity Beneficiary Designation – Annuity Owner (PDF).
DHS-5037 Issuer of Annuity Notice of Obligation (PDF).
DHS-5143 MHCP Required Annuity Information (PDF).
DHS-5181 Lead Agency Case Manager/Worker Communication Form (PDF).
DHS-5532 Annuity Data Worksheet (PDF).
Page 3
Introduction