Get Mn Dhs-4022c-eng 2017-2025

The MN DHS-4022C-ENG form is an essential document for notifying the Minnesota Department of Human Services (DHS) regarding the employment status of Qualified Professionals (QPs) within Personal Care Assistance (PCA) agencies. This guide provides a clear, step-by-step process to assist users in completing the form online efficiently.

Follow the steps to complete the MN DHS-4022C-ENG online

1. Click ‘Get Form’ button to obtain the form and access it in your editing platform.
2. Begin by entering the name of your PCA agency in the designated field. Ensure you print or type the business name clearly.
3. Input the PCA agency's National Provider Identifier (NPI) or Unique Minnesota Provider Identifier (UMPI) in the appropriate section.
4. Fill in the address of the PCA agency, including city, state, and ZIP code.
5. Enter the name of the agency representative who is completing the form, along with their signature for validation.
6. In the section for the Qualified Professional, provide their last name, first name, and middle name as required.
7. Fill in the residential address of the Qualified Professional, including city, state, and ZIP code.
8. Document the date the Qualified Professional has registered for or completed the 'Steps for Success' training.
9. Indicate the date of employment for the Qualified Professional.
10. Write down the license number and the state of issuance for the Qualified Professional.
11. Enter the background study ID number that has been assigned to the Qualified Professional.
12. Confirm the Qualified Professional's date of birth and social security number in the respective fields.
13. Record the background study clearance date to certify their clearance status.
14. Provide the phone number of the Qualified Professional.
15. If the affiliation of the Qualified Professional has ended, check the box provided and enter the end date.
16. Lastly, review all the information you have entered for accuracy. Once satisfied, you can save changes, download, print, or share the completed form.

Complete your MN DHS-4022C-ENG form online now to ensure your documentation is accurate and submitted on time.