Author: cj@minneapolismade.com

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Metro StairLift is a Minnesota based Accessibility company with over 30 years of experience in construction.

CAPS LIC: September 2012
MN Elevator Lic: LC 716918
MN Builders Lic: BC 590012
NPI/UMPI #1669715397

DHS WAIVER FORM

1
Step 1

DHS Waiver Referral Form

Clients Information

Clients NameClients Name

Clients Phone

Clients Emaila valid email

Clients AddressClients Address

Is there a contact person other than the client?

YesNo

Contact Person

Contact Persons Full Name Nameyour full name

Contact Persons Phone NumberContact Persons Phone Number

Contact Persons Email AddressContact Persons Email Address

Contact Persons AddressContact Persons Address

Case Manager Information

Case Managers Full Nameyour full name

Case Managers Phoneyour full name

Company NameCompany Name

Case Managers Email Addressa valid email

Brief Description of Modifications Needed.more details

0 / 500

Is the client the property owner?

YesNo

If the client is not the property owner do they have written permisions for the modification?

YesNo

Specify DHS Waiver

Community Access for Disability Inclusion (CADI)Crain Injury (BI)Developmental Disabilities (DD)Community Alternative Care (CAC)Elderly Waiver (EW)

If you have any documents related to the modification please upload them here. Accepted formats are .pdf, .doc, .docx, .png, and .jpg

Any Documentsupload

Upload

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