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.
Organizational Tip: You will be provided with additional forms throughout the LTC Training Sequence. To help keep these forms organized, we encourage you to put all forms into a separate section of your handout binder or a separate binder. This will make it easier to quickly locate a form as you work through the courses and to transport forms to the MA-LTC Systems classroom course.
DHS-1503 Long Term Care Physician Certification (PDF).
DHS-2497 LTCC Brochure (PDF).
DHS-2977 Important Notice and Parental Fee Worksheet (PDF).
DHS-2982 County Parental Fee Referral to DHS form (PDF).
DHS-3050 LTC/County Communication Form (PDF).
DHS-3203 MA Lien Worksheet (PDF).
DHS-3531 MHCP Application for Long-Term Care Services (PDF).
DHS-3543 MHCP Request for Payment of Long-Term Care Services (PDF).
DHS-3543A Request of Long-Term Care Service (Families with Children and Adults) (PDF)
DHS-3876 MHCP Application for Certain Populations (PDF)
DHS-4915 Notice of Action for Payment of Long-Term Care of Services (PDF).
DHS-5181 Lead Agency Case Manager/ Worker Communication Form (PDF).
DHS-5426A Permission to Share Long-Term Care Insurance Information (PDF).
DHS-5590 MA-LTC Case Checklist (PDF).
DHS-6696 MNsure Application for Health Coverage and Help Paying Costs (PDF)
DHS-6696A Supplement to MNsure Application (DHS6696) for Health Coverage and Help Paying Costs (PDF)
DHS-6696B Supplement to the MHCP Application (DHS-3417) or (DHS-3876) (PDF)
Page 3
Introduction