DHS-6759H-ENG 5-24 (2.0.1)

Moving Home Minnesota Communication Form

Participant information

PMI

FIRST NAME

LAST NAME

DATE OF BIRTH

SOCIAL SECURITY NUMBER

SSN (value, hidden, bound to schema)

Reason for communication

DISENROLLMENT EFFECTIVE DATE

DISENROLLMENT REASON

DESCRIBE OTHER REASON

RE-INSTITUTIONALIZED EFFECTIVE DATE

RE-INSTITUTIONALIZED REASON

DESCRIBE OTHER REASON

PROGRESS TOWARDS COMMUNITY TRANSITION

REASON FOR EXTENSION REQUEST

ANTICIPATED TIME AND UNITS REQUESTED

Will the participant be enrolling in a waiver?

Yes

TYPE OF WAIVER

SPECIFY OTHER REASON

Type of claim

NOTE: Submit up to 4 claims regarding the participant listed above. For additional claims, please fill out another form.

Claim

Transaction Control Number (Claim Number)

Beyond 180 days of Transition Coordination

RSC and MHM in the same month

Transition Planning Tool

Type of document

DESCRIBE OTHER

Attach documentation selected above. Only PDF, Word, Excel, JPG, GIF, PNG or text files may be uploaded.

Community housing information

ESTIMATED MOVE-IN DATE

PHONE NUMBER

Does participant live with family members?

Yes

STREET ADDRESS

CITY

STATE

ZIP CODE

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

All of the items listed must be checked to be regarded as a qualified community residence:

An individual lease

Lockable access and egress

Living, sleeping, bathing, cooking areas in which the participant of the participant's family hass access or control. (Please see attestation statement below if the facility offers shared amenities.)

I attest the participant was given and made an informed choice to live in a facility that offers shared amenities.

NAME OF PROVIDER

LICENSE TYPE

LICENSE CAPACITY

LICENSE NUMBER

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

HOUSING TYPE

MOVE-IN DATE

SPECIFY OTHER

Person submitting form

FIRST NAME

LAST NAME

PHONE NUMBER

AGENCY

NPI

EMAIL ADDRESS

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

Yes