Forms and resources for certified BHH services providers

Providers must be certified by the Minnesota Department of Human Services (DHS) to deliver behavioral health home (BHH) services to people enrolled in Medical Assistance (MA). Learn more about the certification criteria and process. The materials listed here are for certified providers.

Forms for use by certified providers

Providers must use these forms, or a similar form where noted, to get enrollee consent and notify managed care plans of an enrollee's eligibility for BHH services.

Notification of Eligibility for BHH Services (DHS-4797)
Form: Notification of Eligibility for BHH Services DHS-4797 (PDF)

Purpose of this form: BHH providers must use this form to notify the person’s managed care organization (MCO) that he or she will begin to receive BHH services.

How to use this form:
- If a person who has been determined eligible for BHH services is enrolled in managed care, use this form to notify the person’s MCO that he or she is beginning BHH services. Fax a copy of this form to the person’s MCO within 30 days of intake.
- Fill in the person’s contact information and contact information for the BHH team.
- Explain to the person and his or her identified supports when to contact the BHH team.
BHH Services Rights, Responsibilities and Consent form (DHS-4797B)
Form: BHH Services Rights, Responsibilities, and Consent (DHS-4797B) (PDF)

Purpose of this form: BHH providers must use this form. It is used for three reasons:
1. To explain what BHH services offer to a person.
2. To obtain the person’s consent to review his or her current diagnostic assessment to determine if the person is eligible for BHH services.
3. To record the person’s consent to receive BHH services if determined eligible.
To be eligible for BHH services, a person must be eligible for Medical Assistance and have a condition that meets the definition of mental illness as described in Minnesota Statutes, 245.462, subdivision 20, paragraph (a), or emotional disturbance as defined in Minnesota Statutes, 245.4871, subdivision 15, clause (2).

How to use this form:
- Explain to a person who might be eligible for behavioral health home services what those services are.
- Explain that by signing this form, the person is giving your agency permission to review a person’s diagnostic assessment to determine if he or she meets the eligibility criteria for BHH services.
- If the person has not had a diagnostic assessment performed within the past 12 months, assist the person in scheduling a diagnostic assessment.
- Explain to the person what the responsibilities are if he or she decides to participate in BHH services.
- Explain what your agency’s responsibilities are as a BHH provider.
- Explain to the person what his or her rights are when he or she is receiving BHH services.
- Explain to the person that he or she can get an interpreter to explain the form by calling the DHS Language Line.
- Explain that if he or she needs accessible formats or assistance with the form, he or she can call 800-657-3739.
Authorization for Release of Protected Health Information (DHS-4797C)
Form: Authorization for Release of Protected Health Information DHS-4797C (PDF)

Purpose of this form: BHH services providers can use this form or a release form that has been developed and approved by their organization. Use this form to obtain a person’s authorization to release his or her protected health information.

How to use this form:
- Explain to the person that one of the goals of behavioral health home services is to make sure that a person’s mental health provider and primary care physician know what is happening in the person’s life. That is why it is helpful to have the person’s authorization to share his or her protected health information.
- Do not tell the person that he or she cannot receive BHH services if he or she refuses to sign an authorization to release the protected health information.
- Explain to the person that he or she can get an interpreter to explain the form by calling the DHS Language Line.
- Explain that if he or she needs accessible formats or assistance with the form, he or she can call 800-657-3739.

Forms and resources for certified BHH services providers

Forms for use by certified providers

BHH services

Additional materials