Access and submit the dispute form

If you are a Tribe or County that has been determined by the Minnesota Department of Human Services to be the agency of financial responsibility for an approved Behavioral Health Fund applicant, but your agency and another Tribe/County agree that the other Tribe/County actually holds financial responsibility.

Complete the form on your computer using the fillable PDF document, then upload it — no printer needed.

• Download the fillable Financial Responsibility dispute form
• Complete it using the fillable PDF fields
• Save your completed document
• Upload the complete application through the human services upload portal

Download the fillable PDF form     |     Submit the dispute form *

* You will be able to download and submit dispute form soon. Check this page again for updates.

Form: DHS-2780-ENG (Still in development)