Important links for HCBS attestation process

Links referenced in the guidebooks and the attestation form

• Home and Community-Based Services (HCBS) Provider Attestation online form: DHS-7176-ENG (PDF)
• HCBS Provider Attestation Hardship Extension Request: DHS-7176A-ENG (PDF)
• DHS Licensing Information Lookup website
• MDH Provider Directory website used for customized living licensed services
• HCBS Residency Agreement Template for Foster Care and Supported Living Services (SLS) under the BI, CAC, CADI and DD Waivers: DHS-7176B-ENG (PDF)

Sample DHS licensing forms

245D licensed services

• Sample Policies and Forms for Intensive Supports and Services (PDF)

245A licensed services

• Grievance Procedure Sample for Family Child Care: DHS-7740 (PDF)

Additional for 245A adult foster care licensed services (not licensed as Community Residential Settings under 245D)

• Individual Resident Placement Agreement (IRPA) (PDF)
• Adult Foster Care (AFC) and Community Residential Setting (CRS) Program Abuse Prevention Plan (PAPP) (PDF)
• Coming soon to the HCBS transitions webpage: Revised Adult Foster Care Program Plan

Additional 245A family adult day licensed services

• Family Adult Day Services Policy and Program Information (PDF)
• Family Adult Day Services Individual Service Delivery Plan (PDF)

Customized living licensed services

• MDH Home Care Bill of Rights webpage with forms

Links to Guidebooks

• HCBS Provider Attestation Guidebook for Day Settings - Adult Day Services: DHS-7176C-ENG (PDF)
• HCBS Provider Attestation Guidebook for Residential Settings - Elderly Waiver Foster Care Services: DHS-7176D-ENG (PDF)
• HCBS Provider Attestation Guidebook for Residential Settings - Customized Living: DHS-7176E-ENG (PDF)
• HCBS Provider Attestation Guidebook for Day Settings - Day Training and Habilitation, Provocational Services and Structured Day: DHS-7176F-ENG (PDF)
• HCBS Provider Attestation Guidebook for Residential Settings - Foster Care and Supported Living Services (SLS) for BI, CAC, CADI and DD Waivers: DHS-7176G-ENG (PDF)