DHS-6979-ENG 1-24 (2.0.8)

MnCHOICES Help Desk Contact Form

Lead agencies (counties, tribal nations and managed care organizations) use this form to request support or help with the MnCHOICES Application or questions about policy and rates. Before submitting this request, consult with your agency’s MnCHOICES or rates mentors as well as review:

MnCHOICES mentors will use this form to:

Submit a technical inquiry – a problem or issue with the MnCHOICES application
Submit a policy inquiry – a problem or issue with the use of policy or practice in the MnCHOICES application
Submit a MnCHOICES request – example assessor certification questions and reports request.

NOTE:

If your question is about the Medicaid Management Information System (MMIS) use the Service Agreement and Screening Document (SASD) Support Team Portal
If your inquiry is not related to MnCHOICES, use the DSD Contact Form.

DATE SUBMITTED

CONTACT INFORMATION

ORGANIZATION NAME (LEAD AGENCY YOU WORK ON BEHALF OF)

LOCATION NAME (AGENCY YOU ARE EMPLOYED BY)

DOC ID

FIRST NAME

LAST NAME

PHONE NUMBER

Are you submitting this form on behalf of another user?

Yes

ADDITIONAL USER INFORMATION

MnCHOICES USER ID

FIRST NAME

LAST NAME

PHONE NUMBER

QUESTION TYPE

Technical (i.e., related to the MnCHOICES Application)

Policy or practice (e.g., assessment, support planning, waivers/AC/ECS, homecare, PCA/CFSS/CDCS, rates, managed care, LTSS, training, homecare, etc.)

Other (e.g., reports, assessor certification questions, etc.)

This question is related to: (Select one. If you need to ask about both areas, submit an additional form.)

User access

Reports and data

Other

Additional information (What is your suggested solution or answer? Do you have tentative next steps? Describe any attachments you are including or any additional information you would like us to understand.)

What is your question or request?

ATTACHMENTS

PROVIDE SCREENSHOTS OR DOCUMENTATION FOR EXAMPLES IF APPLICABLE

Only PDF, Word, Excel, JPG, GIF, PNG, BMP or HTML files may be uploaded.

DESCRIBE ATTACHMENTS

MnCHOICES Help Desk Contact Form

CONTACT INFORMATION

ADDITIONAL USER INFORMATION

TECHNICAL

POLICY OR PRACTICE

ATTACHMENTS