DHS-4611 Provider Agreement
MHCP Individual Direct Support Worker Provider Agreement — filled onto the official DHS form.
DHS-4611 — MHCP Individual Direct Support Worker (CDCS, CSG, PCA, CFSS) Provider Agreement.
By signing you agree to the provider conditions on the official DHS form: documentation standards under Minn. Stat. §256B.0659; cooperation with DHS, DHHS, and the Medicaid Fraud Control Unit; accepting DHS payment as payment in full; nondiscrimination; safeguarding protected data (Ch. 13, HIPAA, and related laws); and the remaining terms A–P. The complete agreement text is embedded in the archived PDF — read it before signing. Electronic initials and signature are accepted (Minn. Stat. §325L).
Page 1 — Acknowledgment
Your initials (electronic accepted)
UMPI (office can complete)
Name of support worker (type or print)
Page 2 — Signature
I am signing this form electronically. My typed/drawn name is my legally binding signature (Minn. Stat. 325L.02(h), 325L.05, 325L.08).
Name of support worker (type or print)
Title
Date
Signature of support worker
Clear
Submit
