North Dakota Department of Health and Human Services Forms

This document is used for requesting reimbursement for childcare expenses related to foster care during the COVID-19 pandemic in North Dakota.

This document is for licensed associate professional counselors in North Dakota to attest their enrollment in Medicaid.

This document is for licensed mental health technicians in North Dakota who want to enroll and attest as a provider.

This Form is used for licensed baccalaureate social workers in North Dakota to attest their enrollment in Medicaid.

This Form is used for licensed master social workers in North Dakota to enroll in Medicaid and provide attestation of their credentials.

This form is used for reporting child care concerns in North Dakota. It allows individuals to raise concerns about the quality or safety of child care facilities in the state.

This document is used for applying for the North Dakota Autism Waiver in North Dakota. It allows individuals with autism to access necessary services and supports.

This form is used for billing and assessment purposes in the Money Follows the Person (MFP) program for nursing services in North Dakota.

This form is used for authorizing the provision of a nursing assessment in the context of the Money Follows the Person program in North Dakota.

This form is used for referring individuals in North Dakota for skilled care and long-term services and supports (LTSS).

This form is used for hospitals in North Dakota to apply for the designation of Acute Cardiac Ready Hospital.

This document provides an overview of the North Dakota Cardiac System's guide for St-Segment Elevation Myocardial Infarction (STEMI), Non-ST-Elevation Myocardial Infarction (NSTEMI), and Acute Coronary Syndrome (ACS). It includes information on the guidelines and protocols followed in North Dakota for these cardiac conditions.

This Form is used for securely transmitting mail to other organizations in North Dakota.

This form is used for monthly reporting of the use of North Dakota's Disaster Response Grant for disaster response and recovery efforts in North Dakota.

This document is an agreement that outlines the terms and conditions for healthcare providers to access and use the North Dakota Immunization Information System (NDIIS), which is a database that stores immunization records in North Dakota.

This form is used for applying for a technology grant in North Dakota.

This document outlines the protocol for conducting alcohol compliance checks in the City of Grand Forks, North Dakota. It provides guidelines and procedures to ensure that businesses are in compliance with alcohol laws and regulations.

This form is used for requesting reimbursement for direct services provided in North Dakota.

This form is used for requesting authorization for the Advanced Emergency Medical Technician (AEMT) Training Course in North Dakota.

This Form is used for requesting authorization to attend an emergency medical dispatch course in North Dakota.

This form is used for registering participants and obtaining physician authorization for an EMS course in North Dakota.

This form is used for enrolling in the North Dakota Medicaid Electronic Remittance Advice (835) program.

This form is used for requesting reimbursement for the coordination of the Rural Trauma Team Development Course in North Dakota.

This Form is used for applying for grant funding and reimbursement for EMS Systems in North Dakota.

This form is used for obtaining consent for assisted reproduction procedures in North Dakota.