• 408 CEDAR AVE SUITE#5 MINNEAPOLIS, MN 55454
  • +952-688-1962
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MN DHS HCBS Referral Form

Minnesota DHS – Home & Community Services Referral Form

245D • PCA • CFSS
Hold My Hand Inc
408 Cedar Ave S, Ste 5, Minneapolis, MN 55454
Phone: 952-688-1962 | Fax: 1-888-651-7390 | info@hmyhand.com
1. Participant Information
2. Responsible Party / Legal Representative
3. Requested Services – MN DHS 245D / HCBS
4. Medical / Functional Summary
5. HIPAA Authorization

I authorize Hold My Hand Inc and Minnesota DHS to collect, use, and disclose my protected health information (PHI) for eligibility determination and service coordination.

6. Signature
HIPAA NOTICE: This form contains Protected Health Information (PHI). Unauthorized disclosure is prohibited per MN DHS policy.

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Head Office

408 CEDAR AVE SUITE#5 MINNEAPOLIS, MN 55454

Office Hours

Monday - Friday 10 AM - 04 PM

  • info@hmyhand.com
  • +952-688-1962
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