DHS-6759H-ENG 9-26 (2.2.13)

Moving Home Minnesota Communication Form

Participant information

PMI

FIRST NAME

LAST NAME

DATE OF BIRTH

SOCIAL SECURITY NUMBER

SSN (value, hidden, bound to schema)

PARTICIPANT'S PHONE NUMBER

Current address

STREET ADDRESS

APT. NUMBER

CITY

STATE

ZIP CODE

Reason for communication

REASON

DISENROLLMENT EFFECTIVE DATE

DISENROLLMENT REASON

NOTE: The disenrollment date must be the date of death.

DESCRIBE REASON RESIDENCE IS NOT QUALIFIED

Non-qualified residence address

STREET ADDRESS

APT. NUMBER

CITY

STATE

ZIP CODE

DESCRIBE OTHER REASON

REINSTITUTIONALIZED ADMISSION DATE

Does the participant have a discharge date?

Yes

DISCHARGE DATE

REINSTITUTIONALIZED REASON

DESCRIBE REASON FOR REINSITITUALIZATION

Is the person still in the qualified institution?

Yes

PROGRESS TOWARDS COMMUNITY TRANSITION

REASON FOR EXTENSION REQUEST

ANTICIPATED NUMBER OF DAYS (Transition coordination may not exceed 90 calendar days)

Will the participant be enrolling in a waiver?

Yes

Has an MHM demonstration case manager been assigned?

Yes

DESCRIBE THE REASON WHY A DCM HAS NOT BEEN ASSIGNED

TYPE OF WAIVER

SPECIFY OTHER REASON

Type of claim

NOTE: Submit up to 4 claims using this communication form. Add additional claims using the plus (+) sign. If there are five or more denied claims to enter, submit an additional communication form.

Claim

Transaction Control Number (Claim Number)

TYPE

RSC and MHM in the same month

Transition Planning Tool

Attachments

You may select and upload multiple files. Only PDF, Word, Excel, JPG, GIF, PNG or text files may be attached.

Attach MHM Service Authorization Plan (MHM SAP), DHS-6759P (PDF)

Attach Professional Statement of Need (PSN), DHS-7122 (PDF)

Attach MHM Transition Planning Tool (TPT) Risk Mitigation and Emergency Backup Planning Tool, DHS-6759J (PDF)

Attach other files

Community housing information

CHANGE TYPE

New

Change

ESTIMATED MOVE-IN DATE

Will the participant live with family members?

Yes

Indicate which type of qualified community residence the MHM participant will be residing, check the setting that applies and provide information as requested:

A home owned or leased by the participant

A home owned or leased by the family member

An apartment with an individual lease, lockable access/egress and living, sleeping, bathing, cooking areas in which the participant of the participant's family has access or control

Licensed assisted living facility

A home in a residential setting (i.e., community residential settings [CRS], adult foster care or family foster care) in which no more than 4 unrelated people live

PLANNED STREET ADDRESS

APT. NUMBER

CITY

STATE

ZIP CODE

NAME OF ASSISTED LIVING PROVIDER

NAME OF PROVIDER

LICENSE NUMBER

LICENSE TYPE

LICENSE CAPACITY

To lookup a license number, go to Minnesota Department of Health (MDH): Health Care Provider Directory.

To lookup a license number, go to Minnesota Department of Human Services (DHS): Licensing Information Lookup.

MHM demonstration case manager assigned

CASE MANAGER FIRST NAME

CASE MANAGER LAST NAME

PHONE NUMBER

MHCP ENROLLED PROVIDER NAME

EMAIL ADDRESS

Waiver case manager assigned

CASE MANAGER FIRST NAME

CASE MANAGER LAST NAME

PHONE NUMBER

LEAD AGENCY

EMAIL ADDRESS

Housing type

Which type of qualified community residence has the MHM participant moved to?

A home owned or leased by the participant

A home owned or leased by the family member

An apartment with an individual lease, lockable access/egress and living, sleeping, bathing, cooking areas in which the participant of the participant's family has access or control

Licensed assisted living residence

A home in a residential setting (i.e., community residential settings (CRS), adult foster care or family foster care) in which no more than 4 unrelated people live

MOVE-IN DATE

Person submitting form

FIRST NAME

LAST NAME

AGENCY

PHONE NUMBER

EMAIL ADDRESS

Would you like a copy of your submitted form emailed to you?

Yes

You must include attachment(s) before submitting.