Forms for Home Care Providers

From this page you can access forms for home care and home management providers and license/registration applicants.

Home care license applications

Applicants must upload a completed application and all required attachments through the MDH application portal: Facility and Provider Licensing System. 

If you are also applying for an Integrated License: Home and Community-Based Services (HCBS) Designation, you may submit that application and its supporting documents at the same time as your home care application—or submit it at a later date. 

• Application for Home Care Licensure: Temporary Basic Home Care (PDF)
• Application for Home Care Licensure: Temporary Comprehensive Home Care (PDF)
• Application for Change of Ownership: Basic Home Care License (PDF)
• Application for Change of Ownership: Comprehensive Home Care License (PDF)
• Application for Registration as a Provider of Home Management Services (PDF)
• Integrated License: Home and Community-Based Services Designation (PDF)

Survey forms

• Survey forms and self-audit tools

Other Forms

• Statement of Home Care Services: Basic License (PDF)
• Statement of Home Care Services: Comprehensive License (PDF)
• Change of Home Care Provider Information Form (PDF)
  Use this form to update the MDH about changes in provider address, administrator/agent, phone number, email address, workers’ compensation insurance, and housing with services locations.
• Notice from Temporary Licensee of Providing Home Care Services (PDF)
  Use this form to inform MDH within five days after beginning to provide home care services to your first client.
• Home Care Revenue Worksheet (PDF)
  This worksheet is to assist providers with calculating their revenue from providing home care services.
• License Closure Form (PDF)
  Use this form to inform MDH if you are closing or not renewing your home care license.