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Qualified Professionals (as defined in Section 2) use this form to confirm that a person meets certain criteria for one or both of the following:
• Medical Assistance Housing Stabilization Services
• Minnesota Housing Support Program
After completing this form, please return to the person or their authorized representative.
This request does not represent an offer of payment on the part of the state, county, or tribe.
I give permission for the Qualified Professional below to release the requested information to the Minnesota Department of Human Services as well as the county or tribe administering the programs. I know that the information will be used to determine my eligibility for the Minnesota Housing Support Program as well as Medical Assistance Housing Stabilization Services. I know this authorization will end one year from the date I sign it.
State and Federal privacy laws protect my records. I know:
• Why I am being asked to release this information
• I do not have to consent to this authorization, but it may affect my benefits or services if I do not give my consent
• I am giving my written consent for this person/agency to give out this information
• I may stop this authorization with a written notice at any time, but this written notice will not affect information the agency has already requested
• The person or agency who gets my information may pass it on to others.
What is your current situation?
A certified disability determination or formal diagnostic assessment is not required (check one).
Mental health professional, licensed school psychologist, a physician, a nurse practitioner, a physician assistant, or certified psychometrist working under the supervision of a licensed psychologist.
Licensed psychologist or school psychologist with experience determining learning disabilities.
Licensed psychiatric registered nurse, licensed psychiatric nurse practitioner, licensed independent clinical social worker (LICSW), licensed professional clinical counselor (LPCC), licensed psychologist (LP), licensed marriage and family therapist (LMFT), or licensed psychiatrist.
Licensed physician, physician's assistant, nurse practitioner, or licensed chiropractor.
Treatment director, alcohol and drug counselor supervisor, or licensed alcohol and drug counselor (LADC).
This Section must be completed by a Qualified Professional. Please identify areas in which the person needs support to find or maintain stable housing.
This Section must be completed by a Qualified Professional or County Designee. Please indicate which support(s) the person needs to access or maintain housing.
This Section must be completed by Behavioral Health Treatment Staff.
Note: Sections 2 and 3 of this form are not required for completion of this section. Residential treatment staff completing this section may be the same as the Qualified Professional listed above.
Treatment facility name:
This field is not part of the form submission.
* indicates a required field