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Minnesota DHS Professional Statement of Need

  1. MN Department of Human Services Professional Statement of Need
  2. Qualified Professionals (as defined in Section 2) use this form to confirm that a person meets certain criteria for one or both of the following:

    • Medical Assistance Housing Stabilization Services

    • Minnesota Housing Support Program

    After completing this form, please return to the person or their authorized representative.

    This request does not represent an offer of payment on the part of the state, county, or tribe.

  3. Do you authorize the Qualified Professional to release your information? (read and sign below)

    I give permission for the Qualified Professional below to release the requested information to the Minnesota Department of Human Services as well as the county or tribe administering the programs. I know that the information will be used to determine my eligibility for the Minnesota Housing Support Program as well as Medical Assistance Housing Stabilization Services. I know this authorization will end one year from the date I sign it.

    State and Federal privacy laws protect my records. I know:

    • Why I am being asked to release this information

    • I do not have to consent to this authorization, but it may affect my benefits or services if I do not give my consent

    • I am giving my written consent for this person/agency to give out this information

    • I may stop this authorization with a written notice at any time, but this written notice will not affect information the agency has already requested

    • The person or agency who gets my information may pass it on to others.

  4. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  5. Allowable qualified professional

    Mental health professional, licensed school psychologist, a physician, a nurse practitioner, a physician assistant, or certified psychometrist working under the supervision of a licensed psychologist.

    Licensed psychologist or school psychologist with experience determining learning disabilities.

    Licensed psychiatric registered nurse, licensed psychiatric nurse practitioner, licensed independent clinical social worker (LICSW), licensed professional clinical counselor (LPCC), licensed psychologist (LP), licensed marriage and family therapist (LMFT), or licensed psychiatrist.

    Licensed physician, physician's assistant, nurse practitioner, or licensed chiropractor.

    Treatment director, alcohol and drug counselor supervisor, or licensed alcohol and drug counselor (LADC).

  6. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  7. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  8. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  9. Section 5: Transition from Residential Treatment to Minnesota Housing Support Program

    This Section must be completed by Behavioral Health Treatment Staff.

    Note: Sections 2 and 3 of this form are not required for completion of this section. Residential treatment staff completing this section may be the same as the Qualified Professional listed above.

  10. Name:

  11. Treatment facility name:

  12. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  13. Leave This Blank:

  14. This field is not part of the form submission.