Individualized Education Program (IEP) resources

Minnesota Health Care Programs (MHCP) providers must use these forms and documents for providing Individualized Education Program (IEP) services. Also refer to the IEP section of the MHCP Provider Manual.

Checklists and logs
- IEP Services Personal Care Assistance Activities Checklist (DHS-4122C) (PDF): Use to document IEP services activities performed by personal care assistant (PCA).
- IEP/IFSP Services Documentation Log (DHS-5085) (PDF): This form is for school and school district staff to document physical therapy; occupational therapy; speech, language or hearing therapy; mental health; nursing; and interpreter services provided to a K-12 student under an IEP or other individualized plan.
- IEP/IFSP Evaluation Documentation Log (DHS-5085A) (PDF): This form is for school and school district staff to document evaluation for physical therapy; occupational therapy; speech-language pathology; mental health; and nursing services provided to a K-12 student under an IEP or other individualized plan.
- IEP/IFSP Services Documentation Log (DHS-5086) (PDF): This is the special transportation trip log for schools and school district IEP transportation providers to complete for reimbursement for services they provide to a K-12 student as authorized by the student's IEP or IFSP plan.
Brochures for Parents
Information for families about IEP services is available in a brochure in the following languages:
Data collection and annual reports
- Use the MHCP Notice of Intent form (DHS-7840) (PDF) to notify MHCP of your intent to bill for IEP or IFSP Mental Health evaluations if your school or school district is new to special education or has never applied to be an option 1 CTSS provider in the past.
- IEP Services Data Collection Form (DHS-3459) (PDF): If your school or school district provides and bills DHS for covered IEP services, use this form to report Medical Assistance encounters and service time annually.
- Individualized Education Program (IEP) Services Annual Data Report Form (DHS-5052) (PDF): Schools need to use this form to report costs of IEP services.
Partners and other resources