DHS-8543-ENG 7-24 (1.0.6)

Shared Master Index (SMI) Business Request Form

This webpage is only for federal, state departments, and county or tribal human services offices, which work to coordinate client services across state and county systems. Clients may participate in multiple county and state programs and be known to various systems. SMI provides a common database for client demographic data and a comprehensive view of client participation.

DHS provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact: 651-431-2670 or 800-657-3739

This business request form should not be used for SMI Access or SMI security requests. Please contact your county/tribal security liaison or state supervisor for SMI access and security questions.

REQUESTER INFORMATION

ORGANIZATION

SPECIFY OTHER IF NOT LISTED

FIRST NAME

LAST NAME

JOB TITLE

WORK EMAIL ADDRESS

CONFIRM EMAIL ADDRESS

WORK PHONE NUMBER

Please enter the address associated with your primary work location. Do not provide your remote address information. If you are not sure what your primary address is, you can look it up on the County and Tribal Nation Offices or MN State Agencies.

WORK STREET ADDRESS 1

WORK STREET ADDRESS 2

CITY

STATE

ZIP CODE

BUSINESS REQUEST DESCRIPTION (Maximum of 2000 characters)

Does this request change administrative functions that are important to your program?

Yes

Check all that apply:

Increase access to benefits or coverage

Improve life, health or public safety for individuals

Expand eligibility or adjust rates

Increase service delivery and timely payment

Increase accuracy and/or improve program integrity

Commissioner and/or Government priority

Please provide information about how this request supports the functions selected above.

Does this change help improve one or more of the following for people served/providers/stakeholders?

Yes

Check all that apply:

Experience

Access

Outcomes

Equity

Safety

How will this change improve the factors that you checked off above?

What is the potential number of people, providers and community partners impacted? (Enter a numeric value)

Will this request bring a program into compliance or closer to meeting a compliance requirement?

Yes

Check all that apply:

State law/regulation

Federal law/regulation

Executive Order

Court Order

Audit Finding

Regulatory Review Finding

Provide additional information regarding compliance including the compliance date, impact if not met, and details about the type of compliance you checked above.

Are there financial impacts if this change is or is not completed?

Yes

Check all that apply:

Impact to secured funding

Impact to operational/administrative funding

Impact to grant funding

Provide explanation of the financial impact including the percentage or magnitude of existing or future funding. Provide additional information such as dates and length of impact along with type of funding.

Does the funding for the request depend on meeting a specific deadline?

Yes

Provide a timeline and funding deadlines that need to be met.

Will this change reduce risk of disruption to clients, providers, employees, or agencies?

Yes

Check all that apply:

Reduce loss of services

Reduce inability to submit and receive payment for services

Reduce risk of losing accreditation/licensure

Reduce barriers to accessing services

Reduce loss of data

Reduce IT service disruption

Reduce security breaches of data or information

Reduce Regulatory Review findings

Please provide more detail about the risk and the mitigation of that risk if this change is completed.

Rate the priority of this request from a 1-10 scale. With 1 being the lowest priority and 10 being the highest priority, what number would it be?

Is there a workaround solution?

Yes

Indicate whether this workaround significantly hinders your business functions or if it has minimal effect on them.

You may upload up to five (5) files to support this request.