Minnesota HCBS referral checklist for families and case managers

A useful home and community-based services (HCBS) referral explains who to contact, what support the person is seeking, and which details still need confirmation. Families, friends, case managers and other people with permission to share information can use the Clemens Health referral form.

This checklist was updated October 5, 2026 to match the form. Submission starts a review; it does not authorize services or guarantee a start date.

Your contact information

Have your first and last name, email, phone number and preferred contact method ready. Select your relationship to the client: family member, friend, case manager, third party, self or other.

Use the contact details of the person who can discuss the referral. In the notes, explain if another person should be included in follow-up and what permission you have to share their information.

Client basics and requested services

The first step asks for client initials, an adult age range, ZIP code, waiver type and urgency. If the waiver is not known, select “Not sure yet.” For someone under 18, contact us to discuss age and service fit before completing the adult form.

Select each service you want to discuss. Our priority service pages explain:

• IHS without training.
• IHS with training.
• Night supervision.

If the IHS options are unclear, read the IHS comparison guide. A checkbox records your request; the case manager and provider still need to confirm the appropriate service and arrangement.

Optional client documents

You can add a support plan, MnCHOICES assessment or other relevant referral documents in “Client basics.” Only share files you have permission to provide. Documents are optional; you can start a conversation without having a complete packet.

The form accepts PDF, DOCX, JPG and PNG files: up to five files, no more than 3 MB each or 4 MB combined. Review the filenames before submission and remove anything selected by mistake. Files are sent with the completed referral, not when you first select them.

If your documents exceed the limit, contact the intake team to arrange how to provide them. Do not omit information needed for safe planning merely to fit an upload limit.

Care details and permission

The second step asks where support would take place and in which county. You can also provide the residence type, proposed weekly hours and notes.

A helpful note identifies the requested days and times, the person's preferences, the support already in place, and what remains unconfirmed. For overnight requests, use the night-supervision planning checklist to describe the schedule and staffing needs.

Confirm permission to share the information before submitting. State which services or hours are already authorized and which are requests for discussion.

Track the next decision

After submission, keep a short list of open questions:

1. Does the service fit the person's needs and living arrangement?
2. Can the provider cover this address and the proposed schedule?
3. What authorization or additional information is still needed?
4. Who will confirm the start date and communicate schedule changes?

Clemens Health's office is in Bloomington. Contact our team about the specific Twin Cities location where care is needed. Start dates depend on service fit, authorization and staffing; an urgent request does not confirm immediate availability.

Start a referral when you are ready to share the basics.

Planning worksheets for the next step

• Write a concise provider brief.
• Track authorization and staffing separately.
• Follow up on a pending referral.

Browse all guides and worksheets.