DHS-6893I-ENG   1-25  (1.0.6)

COMMUNITY FIRST SERVICES AND SUPPORTS (CFSS)

CFSS Request Form

Lead agency staff complete and submit this form to request technical changes or corrections. Use this form only when corresponding CFSS assessment data already has been entered in MMIS. DHS will deny all other requests.

Request Type

What type of change is this?

Provide details in the service request section.

Provide details in the service request section.

Person's Information

Service Request

Enter the information for the services you are changing:

Click the + icon to add a service

Requestor's Information

Additional Information