Get Mn Dhs-4022c-eng 2021-2025

This guide provides clear and detailed instructions on how to fill out the MN DHS-4022C-ENG form online. The Minnesota Health Care Programs (MHCP) Qualified Professional Acknowledgement form is essential for notifying the Department of Human Services (DHS) about the employment status or credentials of qualified professionals in personal care assistance (PCA) agencies.

Follow the steps to complete the MN DHS-4022C-ENG efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your PCA agency information by filling out the name of the PCA agency, NPI or UMPI, street address, city, state, zip code, and the name of the agency representative. Ensure all details are accurate.
3. Indicate whether you are signing the form electronically by checking the appropriate box. Remember that your typed name in the signature field serves as a legally binding signature.
4. Complete the certification section by acknowledging your understanding of the qualifications, responsibilities, and duties of a qualified professional (QP) within the PCA agency.
5. Fill out the qualified professional information section, including the QP's last name, first name, middle name, street address, city, state, zip code, license number, and background study details.
6. Enter the dates for the completion of the 'Steps for Success' training, employment, background study clearance, and the QP’s date of birth and social security number.
7. If applicable, check the box to indicate that the person’s affiliation has ended. Enter the end date if needed.
8. After filling out all required sections accurately, review the information for completeness and correctness. Once verified, you can save changes, download, print, or share the form as necessary.

Take action now and complete the MN DHS-4022C-ENG form online to ensure proper processing.