PrimeWest Health Contracting Forms and Documents

PrimeWest Health Enrollment Forms

  1. Home and Community Based Waivered Services Provider Enrollment Application
  2. Request for Taxpayer Identification Number and Certification (W-9) form
  3. Home and Community Based Service Providers Criminal Background Check Verification List – as applicable
  4. Disclosure of Ownership and Control Interest of an Entity

Assurance Statements

  1. Adult Day Services Providers Applicant Assurance Statement
  2. Adult Companion Services Providers Applicant Assurance Statement
  3. Assistive Technology Providers Applicant Assurance Statement
  4. HCBS Lead Agency Provider Enrollment Request Form
  5. Chore Service Providers Applicant Assurance Statement
  6. Customized Living Providers Applicant Assurance Statement
  7. Elderly Waiver/Alternative Care (EW/AC) Family Caregiver Training and Education Providers Applicant Assurance Statement
  8. Environmental Accessibility Providers Applicant Assurance Statement
  9. Family Training and Counseling Providers Applicant Assurance Statement
  10. Home Delivered Meals Providers Applicant Assurance Statement
  11. Homemaker Providers Applicant Assurance Statement
  12. Personal Emergency Response System Providers Applicant Assurance Statement
  13. Provider Assurance Statement for Telemedicine
  14. Specialized Supplies and Equipment Providers Applicant Assurance Statement
  15. Transitional Service Providers Applicant Assurance Statement
  16. Waiver Transportation Providers Applicant Assurance Statement

Minnesota Department of Human Services (DHS) Forms and Documents

  1. Service Request Form for HCBS Waiver, Alternative Care (AC), Moving Home Minnesota or Essential Community Supports (DHS-6638)
  2. Waiver and Alternative Care (AC) Programs – Provider Enrollment Application (DHS-4015)
  3. Minnesota Health Care Programs (MHCP) Provider Agreement (DHS-4138)
  4. Lead Agency Provider Enrollment Request Form (DHS-6383)
  5. Provider Not Required to Receive a 245D Program License Applicant Assurance Statement
    (DHS-6189Z)
  6. Disclosure of Ownership and Control Interest of an Entity (DHS-5259)
  7. Designation of HCBS Waiver or AC Program Billing Person (DHS-6855)
  8. Supported Employment Service Providers – Moving Home Minnesota – Applicant Assurance Statement (DHS-3873)