Pre-Application Worksheet for NEW 245D License Applicants 2025

1. Click ‘Get Form’ to open the Pre-Application Worksheet in our editor.
2. Begin by determining the type of 245D service(s) you intend to provide. Select from Basic Support Services or Intensive Support Services as applicable.
3. Next, identify the type of license holder. Choose between 'individual' or 'nonindividual' and provide the necessary details.
4. Provide your tax identification information, including your Minnesota Tax ID and Federal Employer ID Number (FEIN), if applicable.
5. Designate an authorized agent from your controlling individuals. Ensure you have a completed notarized signature form ready for upload.
6. Identify all controlling individuals involved in your organization, providing their full legal names and relevant details.
7. Designate a sensitive background study information person responsible for maintaining background study documentation.
8. Designate a compliance officer who will ensure adherence to Medical Assistance laws and regulations.
9. Determine your program name and location, ensuring that all addresses are complete and accurate.
10. Complete any additional required documentation as specified in the worksheet, ensuring all files are in PDF format for submission.
11. Call the licensor to complete your online application, ensuring you have all documents prepared for review during the call.
12. Finally, complete the Home and Community Based Services Waiver & Alternative Care - Provider Training 101 as required.

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