Follow the steps to complete the worksheet online

1. Click ‘Get Form’ button to obtain the form and open it in your designated editing tool.
2. Identify the type of license holder: Carefully read the definitions and select either ‘individual’ or ‘nonindividual’ as your license type, ensuring you choose only one option.
3. Input the legal name of the license holder: For nonindividual license holders, enter the full business name as it appears in the tax documents. For individual applicants, provide your name as it appears on your ID.
4. Provide tax identification information: Enter your Minnesota Tax Identification Number and Federal Employer ID Number if applicable. Include your Social Security Number only if you are claiming individual status.
5. Declare controlling individuals: List all individuals or organizations that comprise your ownership or management structure as controlling individuals, including their names and titles.
6. Designate an authorized agent: Choose one of the controlling individuals as your authorized agent responsible for communication with the Department of Human Services. Provide their contact details.
7. Identify the sensitive background study information person: Name the individual who will maintain all background study documentation and provide their contact details.
8. Designate a compliance officer: If applicable, enter details for a compliance officer responsible for adhering to Medical Assistance laws and regulations.
9. Specify the services to be provided: Choose the types of services you intend to offer under this license from the provided options.
10. Provide program name and location: Enter the primary program name, associated addresses, and contact information.
11. List any additional program names and locations you wish to include.
12. Complete facility information: If applicable, fill out the details of the facility where services will be provided, including its name and address.
13. Review and attach additional documentation: Ensure you have required documentation ready, such as the organization chart and program policies, as specified.
14. Finalize and submit your worksheet: Save your changes and ensure that all necessary fields have been completed before downloading, printing, or sharing the form.

Start completing the 245d Pre Application Worksheet online today!