DHS-5032-ENG   9-24 (2.1.2)

Moving Home Minnesota (MHM) Intake Form

By submitting this form, if you are found to be eligible, you are consenting to receive Moving Home Minnesota: Money Follows the Person demonstration services. The information you give us will be used to provide the service you are requesting. We ask for this information to tell you apart from other people with the same or similar names and to determine if you are eligible for MHM. Providing this information is voluntary, you can choose not to provide the information. However, if you choose not to provide information, we may not be able to determine your eligibility and enrollment for MHM. The information you provide may be shared with:

  • staff within Moving Home Minnesota.
  • staff in the statewide system whose jobs require access to your information.

You understand the conditions for participation described here:

  • Moving Home Minnesota will not affect your eligibility for Medical Assistance (MA).
  • You may end Moving Home Minnesota services at any time.
  • If you do not want to receive Moving Home Minnesota demonstration services, do not submit this form.
  • You should expect a response from the Minnesota Department of Human Services (DHS) regarding your eligibility for Moving Home Minnesota services within 30 days of submitting this request.

Participant Information

Eligibility

Read and answer the following questions in regard to your eligibility and enrollment

What is the last date you received RSC?

6. Provide your Licensed Alcohol and Drug Counselor (LADC) information

If I decline to sign, I may not be eligible to receive the services that are requested.

Authorization/Consent

I authorize Moving Home Minnesota to contact the above listed LADC to confirm I meet all federal eligibility requirements for Moving Home Minnesota to provide me with eligibility and enrollment support. 

Moving Home Minnesota will only obtain information necessary to administer and authorize the requested services. The reason for the authorization and consent is to assist in coordination related to the provision of Moving Home Minnesota eligibility and enrollment. 

You are not legally required to provide the requested consent and authorization and may decline to provide. However, without the requested information Moving Home Minnesota will not be able to determine your eligibility.

By checking "I agree" and typing my name in the "Electronic Signature" field, I understand that I am electronically signing this form. I attest and certify that the information provided above is true and accurate. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. (MN Stat. §325L.07)

Client

Parent/Guardian/Authorized Representative

Person completing this form

If someone other than the participant is completing this form, you attest that you have spoken to the participant and confirmed their intent to enroll in Moving Home Minnesota, a Money Follows the Person demonstration. You cannot complete this application on their behalf without their consent.