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Get MN DHS-6249-ENG 2016-2024

NAME PROVIDER NPI SERVICE TYPE ACTUAL LEVEL OF CARE PROVIDED SERVICE(S) RECIPIENT IS RECEIVING OR REFERRED TO REASON FOR VARIANCE (if applicable) I. Risk of Harm 1. Minimal 2. Low 3. Moderate 4. Serious 5. Extreme IV-B. Recovery Environment – Level of support 1. Highly Supportive 2. Supportive 3. Limited Support 4. Minimal Support 5. No Support II. Functional Status 1. Minimal 2. Mild 3. Moderate 4. Serious 5. Severe V. Treatment and Recovery History 1. .

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