F-11129A |
Tribal and Out-of-State Federally Qualified Health Center Cost Report Completion Instructions |
DMS |
English |
01/2021 |
PDF |
No |
F-11130 |
Tribal and Out-of-State Federally Qualified Health Center |
DMS |
English |
01/2021 |
Excel |
No |
F-02758 |
Federally Qualified Health Center Outstationed Enrollment Survey |
OIG |
English |
01/2021 |
Excel |
No |
F-11129 |
Tribal and Out-of-State Federally Qualified Health Center Cost Report Forms |
OIG |
English |
01/2021 |
Excel |
No |
F-00401 |
Preferred Drug List (PDL) Expedited Emergency Supply Request |
DMS |
English |
01/2021 |
PDF |
No |
F-00401 |
Preferred Drug List (PDL) Expedited Emergency Supply Request, Instructions |
DMS |
English |
01/2021 |
PDF |
No |
F-02463 |
Tuberculosis (TB) Treatment Assistance Program - Request for Reimbursement |
DPH |
English |
01/2021 |
PDF |
No |
F-00401 |
Preferred Drug List (PDL) Expedited Emergency Supply Request |
DMS |
English |
01/2021 |
Word |
No |
F-02746 |
Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities |
DMS |
English |
12/2020 |
Word |
No |
F-02746 |
Request for Institution of Mental Disease Determination for Residential Substance Use Disorder Facilities |
DMS |
English |
12/2020 |
PDF |
No |
F-02500 |
Facility Referral to ADRC/Tribal ADRS for Publicly Funded Long-Term Care |
DPH |
English |
12/2020 |
Word |
No |
F-44192 |
Child Care Immunization Record |
DPH |
English |
12/2020 |
PDF |
No |
F-02383 |
HCBS Heightened Scrutiny Reviewer Assessment and Evidentiary Summary |
DMS |
English |
12/2020 |
Word |
No |
F-44192S |
Child Care Immunization Record, Spanish |
DPH |
Spanish |
12/2020 |
PDF |
No |
F-00052C |
Organizational Transition for Dementia Care Specialist |
DPH |
English |
11/2020 |
Word |
No |
F-20985RY |
Participant Rights and Responsibilities Notification, Rohingya |
DMS |
Rohingya |
11/2020 |
PDF |
No |
F-20985S |
Participant Rights and Responsibilities Notification, Spanish |
DMS |
Spanish |
11/2020 |
Word |
No |
F-20985 |
Participant Rights and Responsibilities Notification |
DMS |
English |
11/2020 |
PDF |
No |
F-20985RY |
Participant Rights and Responsibilities Notification, Rohingya |
DMS |
Rohingya |
11/2020 |
Word |
No |
F-20985H |
Participant Rights and Responsibilities Notification, Hmong |
DMS |
Hmong |
11/2020 |
PDF |
No |
F-20985S |
Participant Rights and Responsibilities Notification, Spanish |
DMS |
Spanish |
11/2020 |
PDF |
No |
F-20985H |
Participant Rights and Responsibilities Notification, Hmong |
DMS |
Hmong |
11/2020 |
Word |
No |
F-20985 |
Participant Rights and Responsibilities Notification |
DMS |
English |
11/2020 |
Word |
No |
F-20985SO |
Participant Rights and Responsibilities Notification, Somali |
DMS |
Somali |
11/2020 |
PDF |
No |
F-20985KA |
Participant Rights and Responsibilities Notification, Karen |
DMS |
Karen |
11/2020 |
PDF |
No |
F-20985SO |
Participant Rights and Responsibilities Notification, Somali |
DMS |
Somali |
11/2020 |
Word |
No |
F-02658A |
COVID-19 Baseline Testing: Resident/Patient/Client Consent |
DQA |
English |
11/2020 |
Word |
No |
F-10112AS |
Medicaid - Disability Application Addendum, Spanish |
DMS |
Spanish |
11/2020 |
PDF |
No |
F-10112AH |
Medicaid - Disability Application Addendum, Hmong |
DMS |
Hmong |
11/2020 |
PDF |
No |
F-10112A |
Medicaid - Disability Application Addendum |
DMS |
English |
11/2020 |
PDF |
No |
F-02721BSO |
Notice of Medical Remedial Expenses, Somali |
DPH |
Somali |
11/2020 |
Word |
No |
F-02721BH |
Notice of Medical Remedial Expenses, Hmong |
DPH |
Hmong |
11/2020 |
Word |
No |
F-02721ASO |
Notice of Delay in Functional Eligibility Determination, Somali |
DPH |
Somali |
11/2020 |
Word |
No |
F-02721AS |
Notice of Delay in Functional Eligibility Determination, Spanish |
DPH |
Spanish |
11/2020 |
Word |
No |
F-02721BR |
Notice of Medical Remedial Expenses, Russian |
DPH |
Russian |
11/2020 |
Word |
No |
F-02721AH |
Notice of Delay in Functional Eligibility Determination, Hmong |
DPH |
Hmong |
11/2020 |
Word |
No |
F-02721BS |
Notice of Medical Remedial Expenses, Spanish |
DPH |
Spanish |
11/2020 |
Word |
No |
F-02721AR |
Notice of Delay in Functional Eligibility Determination, Russian |
DPH |
Russian |
11/2020 |
Word |
No |
F-02721A |
Notice of Delay in Functional Eligibility Determination |
DPH |
English |
11/2020 |
Word |
No |
F-02721B |
Notice of Medical Remedial Expenses |
DPH |
English |
11/2020 |
Word |
No |
F-02595 |
Request for Approval: Youth Crisis Stabilization Facilities (YCSF) Certification Application |
DCTS |
English |
10/2020 |
Word |
No |
F-02737A |
COVID Impact Survey for Behavioral Health Providers - Prep |
DCTS |
English |
10/2020 |
PDF |
No |
F-02738 |
Family Care Partnership Appeal Decision Letter |
DMS |
English |
10/2020 |
Word |
No |
F-02739 |
Family Care Partnership Letter about Your Right to Make a Fast Complaint |
DMS |
English |
10/2020 |
Word |
No |
F-02737 |
COVID Impact Survey for Behavioral Health Providers - Prep |
DCTS |
English |
10/2020 |
HTML |
No |
F-02734 |
Nursing Home Notification of Intent to Use Asymptomatic, COVID Positive Staff |
DQA |
English |
10/2020 |
Word |
No |
F-02731 |
Line List: Respiratory Virus Outbreak - Workplace Environment |
DPH |
English |
10/2020 |
Excel |
No |
F-02730 |
Worker COVID-19 Symptoms Screening |
DPH |
English |
10/2020 |
Excel |
No |
F-02729 |
Workplace Plan -Contact Tracing Planning Checklist |
DPH |
English |
10/2020 |
Excel |
No |
F-49357S |
Personal Diabetes Care Record, Spanish |
DPH |
Spanish |
10/2020 |
PDF |
No |