When you are due to renew your Medical Assistance eligibility, you will receive a notice from DHS explaining what you need to do. Processing will be delayed if you send an unsigned or incomplete renewal form that requires more information. Last updated: 05/27/2020. For all applicants, How to Use Your Minnesota EBT Card (DHS-3315A) (PDF). More information is in the Your Responsibilities brochure (PDF). Go to the Department of Human Services' (DHS) e-Docs site and search for the form by entering the DHS form number. Give the following forms/handouts based on the programs applied for and the circumstances of the case at the interview or send them out if the interview is conducted over the phone. Denial and notice actions: We may deny or change your cash or health care and/or food support benefits because of information you give on this form. If you have not returned your renewal form, you must return it by the due date or your eligibility will end December 31. Forms. ADDITIONAL PROGRAM SPECIFIC FORMS You can print the form. Court Forms do not yet adhere to accessibility standards. The Minnesota Department of Human Services (Department) supports the use of People First language. 0026.12.12 - WHEN NOT TO GIVE ADDITIONAL NOTICE, 0026.12.15 - WHEN TO GIVE RETROACTIVE OR NO NOTICE, 0026.12.21 - VOLUNTARY REQUEST FOR CLOSURE NOTICE, 0026.15 - NOTICE OF DENIAL, TERMINATION, OR SUSPENSION, 0026.21 - NOTICE OF CHANGE IN ISSUANCE METHOD, 0026.24 - NOTICE OF RELATIVE CONTRIBUTION. See 0010.18 (Mandatory Verifications). 0002.05 - GLOSSARY: ASSISTANCE STANDARD 0002.17 - GLOSSARY: DISPLACED HOMEMAKER 0002.41 - GLOSSARY: MEDICALLY NECESSARY 0003 - CLIENT RESPONSIBILITIES AND RIGHTS, 0003.03 - CLIENT RESPONSIBILITIES - GENERAL, 0003.06 - CLIENT RESPONSIBILITIES - QUALITY CONTROL, 0003.09.03 - CLIENT RIGHTS - CIVIL RIGHTS, 0003.09.06 - CLIENT RIGHTS - DATA PRIVACY PRACTICES, 0003.09.09 - CLIENT RIGHTS, PRIVATE AND CONFIDENTIAL DATA, 0003.09.12 - CLIENT RIGHTS - LIMITED ENGLISH PROFICIENCY, 0004.01 - EMERGENCIES - PROGRAM PROVISIONS, 0004.03 - EMERGENCY AID ELIGIBILITY - CASH ASSISTANCE, 0004.04 - EMERGENCY AID ELIGIBILITY--SNAP/EXPEDITED FOOD, 0004.06 - EMERGENCIES - 1ST MONTH PROCESSING, 0004.09 - EMERGENCIES - 2ND AND 3RD MONTH PROCESSING, 0004.12 - VERIFICATION REQUIREMENTS FOR EMERGENCY AID, 0004.15 - EMERGENCIES - POSTPONED VERIFICATION NOTICE, 0004.18 - DETERMINING THE AMOUNT OF EMERGENCY AID, 0004.48 - DESTITUTE UNITS--MIGRANT/SEASONAL FARMWORKER, 0004.51 - DESTITUTE UNITS, ELIGIBILITY AND BENEFITS, 0005.06.03 - WHO CAN/CANNOT BE AUTHORIZED REPRESENTATIVES, 0005.06.06 - DISQUALIFYING AUTHORIZED REPRESENTATIVES, 0005.09 - COMBINED APPLICATION FORM (CAF), 0005.09.03 - WHEN PEOPLE MUST COMPLETE AN APPLICATION, 0005.09.06 - WHEN NOT TO REQUIRE COMPLETION OF AN APPLICATION, 0005.09.09 - WHEN TO USE AN ADDENDUM TO AN APPLICATION, 0005.09.15 - EMERGENCY ASSISTANCE AND APPLICATIONS, 0005.10 - MINNESOTA TRANSITION APPLICATION FORM (MTAF), 0005.12 - ACCEPTING AND PROCESSING APPLICATIONS, 0005.12.03 - WHAT IS A COMPLETE APPLICATION, 0005.12.12.01 - FORMS/HANDOUTS FOR APPLICANTS, 0005.12.12.06 - ORIENTATION TO FINANCIAL SERVICES, 0005.12.12.09 - FAMILY VIOLENCE PROVISIONS/REFERRALS, 0005.12.15 - APPLICATION PROCESSING STANDARDS, 0005.12.15.01 - PROCESSING SNAP APPLICATION NON-MANDATORY VERIFICATION, 0005.12.15.03 - DELAYS IN PROCESSING APPLICATIONS, 0005.12.15.06 - DETERMINING WHO CAUSED THE DELAY, 0005.12.15.09 - DELAYS CAUSED BY THE APPLICANT HOUSEHOLD, 0005.12.15.12 - DELAYS CAUSED BY THE AGENCY, 0005.12.15.15 - DELAYS CAUSED BY THE AGENCY AND APPLICANT, 0005.12.21 - REINSTATING A WITHDRAWN APPLICATION, 06 - DETERMINING FINANCIAL RESPONSIBILITY, 0006 - DETERMINING FINANCIAL RESPONSIBILITY, 0006.06 - MOVING BETWEEN COUNTIES - PARTICIPANTS, 0006.09 - MOVING BETWEEN COUNTIES - MINOR CHILDREN, 0006.12 - ASSISTANCE TERMINATED WITHIN LAST 30 DAYS, 0006.15 - MULTIPLE COUNTY FINANCIAL RESPONSIBILITY, 0006.18 - EXCLUDED TIME FACILITIES AND SERVICES, 0006.21 - TRANSFERRING RESPONSIBILITY - OLD COUNTY, 0006.24 - TRANSFERRING RESPONSIBILITY - NEW COUNTY, 0006.27 - COUNTY FINANCIAL RESPONSIBILITY DISPUTES, 0006.30 - STATE FINANCIAL RESPONSIBILITY DISPUTES, 0007.03.01 - MONTHLY REPORTING - UNCLE HARRY FS, 0007.03.04 - SIX-MONTH REPORTING DEADLINES, 0007.03.07 - PROCESSING A LATE COMBINED SIX-MONTH REPORT, 0007.12 - AGENCY RESPONSIBILITIES FOR CLIENT REPORTING, 0007.15 - UNSCHEDULED REPORTING OF CHANGES - CASH, 0007.15.03 - UNSCHEDULED REPORTING OF CHANGES - SNAP, 0008.03 - CHANGES - OBTAINING INFORMATION, 0008.06 - IMPLEMENTING CHANGES - GENERAL PROVISIONS, 0008.06.01 - IMPLEMENTING CHANGES - PROGRAM PROVISIONS, 0008.06.03 - CHANGE IN BASIS OF ELIGIBILITY, 0008.06.06 - ADDING A PERSON TO THE UNIT - CASH, 0008.06.07 - ADDING A PERSON TO THE UNIT - SNAP, 0008.06.09 - REMOVING A PERSON FROM THE UNIT, 0008.06.12.09 - CONVERTING A PREGNANT WOMAN CASE, 0008.06.15 - REMOVING OR RECALCULATING INCOME, 0008.06.21 - CHANGE IN COUNTY OF RESIDENCE, 0008.06.24 - DWP CONVERSION OR REFERRAL TO MFIP, 0009.03 - LENGTH OF RECERTIFICATION PERIODS, 0009.03.03 - WHEN TO ADJUST THE LENGTH OF CERTIFICATION, 0009.06.03 - RECERTIFICATION PROCESSING STANDARDS, 0009.06.03.03 - PROCESSING SNAP RECERTIFICATION NON-MANDATORY VERIFICATION, 0010.03 - VERIFICATION - COOPERATION AND CONSENT, 0010.06 - SOURCES OF VERIFICATION - DOCUMENTS, 0010.09 - SOURCES OF VERIFICATION, COLLATERAL CONTACTS, 0010.12 - SOURCES OF VERIFICATION - HOME VISITS, 0010.15 - VERIFICATION - INCONSISTENT INFORMATION, 0010.18.01 - MANDATORY VERIFICATIONS - CASH ASSISTANCE, 0010.18.02 - MANDATORY VERIFICATIONS - SNAP, 0010.18.02.03 - NON-MANDATORY VERIFICATIONS - SNAP, 0010.18.03 - VERIFYING SOCIAL SECURITY NUMBERS, 0010.18.03.03 - VERIFYING SOCIAL SECURITY NUMBERS - NEWBORNS, 0010.18.05 - VERIFYING DISABILITY/INCAPACITY - CASH, 0010.18.06 - VERIFYING DISABILITY/INCAPACITY - SNAP, 0010.18.08 - VERIFYING STATE RESIDENCE - CASH, 0010.18.09 - VERIFYING SELF-EMPLOYMENT INCOME, 0010.18.11 - VERIFYING CITIZENSHIP AND IMMIGRATION STATUS, 0010.18.11.03 - SYSTEMATIC ALIEN VERIFICATION (SAVE), 0010.18.12 - VERIFYING LAWFUL TEMPORARY RESIDENCE, 0010.18.15 - VERIFYING LAWFUL PERMANENT RESIDENCE, 0010.18.15.03 - LAWFUL PERMANENT RESIDENT: USCIS CLASS CODES, 0010.18.15.06 - VERIFYING SOCIAL SECURITY CREDITS, 0010.18.18 - VERIFYING SPONSOR INFORMATION, 0010.18.21 - IDENTIFY NON-IMMIGRANT OR UNDOCUMENTED PEOPLE, 0010.18.21.03 - NON-IMMIGRANT PEOPLE: USCIS CLASS CODES, 0010.18.30 - VERIFYING STUDENT INCOME AND EXPENSES, 0010.24 - INCOME AND ELIGIBILITY VERIFICATION SYSTEM, 0010.24.03 - IEVS MATCH TYPE AND FREQUENCY, 0010.24.09 - PROCESSING IEVS MATCHES TIMELY, 0010.24.12 - DETERMINING IEVS EFFECT ON ELIGIBILITY, 0010.24.15 - RECORDING IEVS RESOLUTION FINDINGS, 0010.24.18 - CLIENT COOPERATION WITH IEVS, 0010.24.21 - IEVS SAFEGUARDING RESPONSIBILITIES, 0010.24.24 - IEVS NON-DISCLOSURE AND EMPLOYEE AWARENESS, 0011.03 - CITIZENSHIP AND IMMIGRATION STATUS, 0011.03.03 - NON-CITIZENS - MFIP/DWP CASH, 0011.03.06 - NON-CITIZENS - MFIP FOOD PORTION, 0011.03.09 - NON-CITIZENS - SNAP/MSA/GA/GRH, 0011.03.12 - NON-CITIZENS - LAWFUL PERMANENT RESIDENTS, 0011.03.12.03 - NON-CITIZENS - ADJUSTMENT OF STATUS, 0011.03.15 - NON-CITIZENS - LPR WITH SPONSORS, 0011.03.17 - NON-CITIZENS - PUBLIC CHARGE, 0011.03.18 - NON-CITIZENS - PEOPLE FLEEING PERSECUTION, 0011.03.21 - NON-CITIZENS - VICTIMS OF BATTERY/CRUELTY, 0011.03.24 - NON-CITIZENS - LAWFULLY RESIDING PEOPLE, 0011.03.27 - UNDOCUMENTED AND NON-IMMIGRANT PEOPLE, 0011.03.27.01 - NON-CITIZENS - CITIZENS OF PALAU, THE FEDERATED STATES OF MICRONESIA, AND THE REPUBLIC OF THE MARSHALL ISLANDS, 0011.03.27.03 - PROTOCOLS FOR REPORTING UNDOCUMENTED PEOPLE, 0011.03.30 - NON-CITIZENS - TRAFFICKING VICTIMS, 0011.03.33 - NON-CITIZENS - IMMIGRATION COURT ORDERS, 0011.06.03 - STATE RESIDENCE - EXCLUDED TIME, 0011.06.06 - STATE RESIDENCE - INTERSTATE PLACEMENTS, 0011.06.09 - STATE RESIDENCE - 30-DAY REQUIREMENT, 0011.12.01 - DRUG ADDICTION OR ALCOHOL TREATMENT FACILITY, 0011.12.03 - UNDER CONTROL OF THE PENAL SYSTEM, 0011.30.06 - 180 TO 60 DAYS BEFORE MFIP CLOSES, 0011.33.02 - MFIP HARDSHIP EXTENSIONS - REMOVING 1 PARENT, 0011.33.03 - MFIP EMPLOYED EXTENSION CATEGORY, 0011.33.03.03 - LIMITED WORK DUE TO ILLNESS/DISABILITY, 0011.33.06 - MFIP HARD TO EMPLOY EXTENSION CATEGORY, 0011.33.09 - MFIP ILL/INCAPACITATED EXTENSION CATEGORY, 0012.06 - REQUIREMENTS FOR CAREGIVERS UNDER 20, 0012.12.03 - INTERIM ASSISTANCE AGREEMENTS, 0012.12.06 - SPECIAL SERVICES - APPLYING FOR SOCIAL SECURITY, 0012.15 - INCAPACITY AND DISABILITY DETERMINATIONS, 0012.15.03 - MEDICAL IMPROVEMENT NOT EXPECTED (MINE) LIST, 0012.15.06 - STATE MEDICAL REVIEW TEAM (SMRT), 0012.15.06.03 - SMRT - SPECIFIC PROGRAM REQUIREMENTS, 0012.21 - RESPONSIBLE RELATIVES NOT IN THE HOME, 0012.21.03 - SUPPORT FROM NON-CUSTODIAL PARENTS, 0012.21.06 - CHILD SUPPORT GOOD CAUSE EXEMPTIONS, 0013.03.03 - PREGNANT WOMAN BASIS - MFIP/DWP, 0013.03.06 - MFIP BASIS - STATE-FUNDED CASH PORTION, 0013.06 - SNAP CATEGORICAL ELIGIBILITY/INELIGIBILITY, 0013.09.09 - MSA BASIS - DISABLED AGE 18 AND OLDER, 0013.15.03 - GA BASIS - PERMANENT ILLNESS, 0013.15.06 - GA BASIS - TEMPORARY ILLNESS, 0013.15.09 - GA BASIS - CARING FOR ANOTHER PERSON, 0013.15.12 - GA BASIS - PLACEMENT IN A FACILITY, 0013.15.27 - GA BASIS, SSD/SSI APPLICATION/APPEAL PENDING, 0013.15.33 - GA BASIS - DISPLACED HOMEMAKERS, 0013.15.39 - GA BASIS - PERFORMING COURT ORDERED SERVICES, 0013.15.42 - GA BASIS - LEARNING DISABLED, 0013.15.48 - GA BASIS - ENGLISH NOT PRIMARY LANGUAGE, 0013.15.51 - GA BASIS - PEOPLE UNDER AGE 18, 0013.15.54 - GA BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.09 - GRH BASIS - DISABLED AGE 18 AND OLDER, 0013.18.12 - GRH BASIS - REQUIRES SERVICE IN RESIDENCE, 0013.18.15 - GRH BASIS - PERMANENT ILLNESS, 0013.18.18 - GRH BASIS - TEMPORARY ILLNESS, 0013.18.27 - GRH BASIS - SSD/SSI APPL/APPEAL PEND, 0013.18.33 - GRH BASIS - LEARNING DISABLED, 0013.18.36 - GRH BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.39 - GRH BASIS - TRANSITION FROM RESIDENTIAL TREATMENT, 0014.03 - DETERMINING THE ASSISTANCE UNIT, 0014.03.03 - DETERMINING THE CASH ASSISTANCE UNIT, 0014.03.03.03 - OPTING OUT OF MFIP CASH PORTION, 0014.06 - WHO MUST BE EXCLUDED FROM ASSISTANCE UNIT, 0014.09 - ASSISTANCE UNITS - TEMPORARY ABSENCE, 0014.12 - UNITS FOR PEOPLE WITH MULTIPLE RESIDENCES, 0015.06.03 - AVAILABILITY OF ASSETS WITH MULTIPLE OWNERS, 0015.30 - ASSETS - PAYMENTS UNDER FEDERAL LAW, 0015.48.03 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-864, 0015.48.06 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-134, 0015.63 - EVALUATION OF PENSION AND RETIREMENT PLANS, 0015.69.03 - ASSET TRANSFERS FROM SPOUSE TO SPOUSE, 0015.69.09 - IMPROPER TRANSFER INELIGIBILITY, 0015.69.12 - IMPROPER TRANSFERS - ONSET OF INELIGIBILITY, 0016 - INCOME FROM PEOPLE NOT IN THE UNIT, 0016.03 - INCOME FROM DISQUALIFIED UNIT MEMBERS, 0016.06 - INCOME FROM INELIGIBLE SPOUSE OF UNIT MEMBER, 0016.09 - INCOME FROM INELIGIBLE STEPPARENTS, 0016.12 - INCOME FROM PARENTS OF ADULT GA CHILDREN, 0016.18 - INCOME OF INEL. Minnesota home care statute requires licensed home care providers and registered home management providers to notify the Minnesota Department of Health (MDH) within ten days . Asset Declaration Patient and Spouse - DHS-4574-B. MFIP: Reporting Responsibilities for MFIP Households (DHS-2647) (PDF). If there is a custodial parent under age 18, the MFIP for Minor Caregivers (DHS-3238) (PDF) brochure. If you need to meet with a worker, you must go to the agency listed on your renewal notice. Also see 0003.09.03 (Clients Rights - Civil Rights). Program information for cash, food, and child care programs (DHS-2920) (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. AFC Recipient Rights Return all required materials to your licensor at: Clay County Social Services. Renewing eligibility and reporting changes for health care programs If you have Medical Assistance (MA) or MinnesotaCare coverage, the Department of Human Services (DHS) must redetermine your eligibility once a year to see whether you are still eligible for health care coverage. Information about the interview and returning the remainder of the CAF. See 0007.12 (Agency Responsibilities for Client Reporting). department of health and human services richard whitley, ms division of welfare and supportive services director steve h. fisher administrator steve sisolak governor. DHS - Family Systems Monitoring Questionnaire. The policies must include an internal reporting procedure, which allows an individual Notice of Requirement to Attend MFIP Overview (DHS-2929) (PDF). Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF). Be sure to follow the instructions on the notice. Human Services. Plenary: A decade later: Safe Harbors evolution in ending sexual exploitation and abuse, Plenary: Improving outcomes: effective collaboration with survivor-leaders, Plenary: Expanding Our Garden Through the Voices of Our Relatives, Plenary: Minnesota Missing and Murdered Indigenous Women Task Force, Minnesota's Safe Harbor regional navigators, Collaborative Intensive Bridging Services, Child support parenting expense adjustment, Child support text pilot print opt-in form, COVID-19 Public Health Support Funds for Child Care, Licensing child care centers landing page, Social Security advocacy and SOAR - short URL directory, Social Security advocacy and SOAR - short URL SSA, Minnesota Health Care Programs Member Help Desk. The importance of returning page number 1 of the CAF as soon as possible. *New* Use Minnesota Guide & File to create forms in certain case types. The premium notices you get in November and December may show a premium amount of unknown instead of a dollar amount. (MN Stat. Facts on Voluntarily Quitting Your Job If You Are on the Supplemental Nutrition Assistance Program (SNAP) (DHS-2707) (PDF). Accident Report (PDF) See 0007.12 (Agency Responsibilities for Client Reporting). Instead, give the applicant the Minnesotas Diversionary Work Program-DWP (DHS-4034) (PDF). Box 107 Minneapolis, MN 55440. ISSUE DATE: 03/2021. SERVICES SANCTIONS, 0028.30.04.03 - POST 60-MONTH SANCTIONS: 2-PARENT PROVISIONS, 0028.30.06 - TYPE/LENGTH OF SNAP E&T SANCTIONS, 0028.30.09 - REFUSING OR TERMINATING EMPLOYMENT, 0028.30.12 - SANCTION NOTICE FOR MINOR CAREGIVER, 0028.33 - EMPLOYMENT SERVICES/SNAP E&T NOTICE REQUIREMENTS, 0029.03.06 - FAMILY SUPPORT GRANT PROGRAM, 0029.03.09 - CONSUMER SUPPORT GRANT PROGRAM, 0029.03.18 - RELATIVE CUSTODY ASSISTANCE PROGRAM, 0029.06.03 - SUPPLEMENTAL SECURITY INCOME PROGRAM, 0029.06.06 - RETIREMENT, SURVIVORS AND DISABILITY INSURANCE, 0029.06.21 - UNITED STATES REPATRIATION PROGRAM, 0029.06.24.03 - TRIBAL TANF - MILLE LACS BAND OF OJIBWE, 0029.06.24.06 - TRIBAL TANF - RED LAKE BAND OF CHIPPEWA INDIANS, 0029.07.09 - WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM, 0029.07.12 - COMMODITY SUPPLEMENTAL FOOD PROGRAM, 0029.07.15 FOOD DISTRIBUTION PROGRAM-INDIAN RESERVATION, 0029.20.09 - FAMILY HOMELESS PREVENTION ASSISTANCE, 0029.27 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM, 0029.31 - CHILD CARE RESOURCE AND REFERRAL, 0030.03.01.01 - INELIGIBLE FOR OTHER CASH PROGRAMS, 0030.03.09 - DETERMINING RCA GROSS INCOME, 0030.03.16 - PROCESSING REPORTED CHANGES - RCA, 0030.03.18 - RCA OVERPAYMENTS AND UNDERPAYMENTS, 0030.12.03 - RCA POST-SECONDARY EDUCATION/TRAINING, 0030.12.06 - RCA EMPLOYMENT SERVICES GOOD CAUSE CLAIMS, Combined Application Form (CAF) (DHS-5223) (PDF), Supplemental Nutrition Assistance Program (SNAP) Application for Seniors (Individuals and couples age 60 and older) (DHS-5223F) (PDF), Notice of Privacy Practices (DHS-3979) (PDF), Client Responsibilities and Rights (DHS-4163) (PDF), Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF), Program information brochure for cash, food, child care and health care programs (DHS-2920) (PDF), Domestic Violence Information (DHS-3477) (PDF), Do you have a disability? If everyone in your household receives MinnesotaCare, call the MinnesotaCare Information Line at 651-297-3862 or 800-657-3672. Mail to Hennepin County Human Services Dept. Mailing: Otter Tail County Department of Human Services, 530 West Fir Avenue, Fergus Falls, MN, USA. Your eligibility was renewed automatically and you don't have to do anything unless you have a change to report. Complete, sign and return the Combined Application Form (CAF) or 6-Month Report, which you will receive in the mail. Continue to pay the amount shown on your invoice. How to Use Your Minnesota EBT Card (DHS-3315A) (PDF). (Minnesota Statutes, chapters 171.04, 171.13, and 171.14; Minnesota Rule 7410.2400) All data collected on this form is private and may not be issued to anyone, with the exception of name and address, which may be provided to law enforcement personnel. 2584 - eg (216.0.0) page 1 of 2. change report form. Change of Office Locations . Family Violence Referral (DHS-3323) (PDF) and Domestic Violence Information (DHS-3477) (PDF). If the program (s) being applied for is known, forms for those programs can be given in the application packet or at the interview, if one is required. General Authorization For Release Of Information To The Tennessee Department Of Human Services - (Spanish) PUBLIC RECORDS REQUESTS. (DHS-4133) (PDF). RESPONSIBILITIES, 0028.03.01 - COUNTY AGENCY SNAP E&T RESPONSIBILITIES, 0028.03.02 - ES PROVIDER RESPONSIBILITIES - SNAP E&T, 0028.03.03 - EMPLOYMENT SERVICES/SNAP E&T REQUIRED COMPONENTS, 0028.03.06 - DETERMINING SNAP PRINCIPAL WAGE EARNER, 0028.03.09 - REPORTING CHANGES TO JOB COUNSELOR, 0028.06.02 - UNIVERSAL PARTICIPATION PROVISIONS, 0028.06.03 - WHO MUST PARTICIPATE IN EMPL. 0026.06 - NOTICE - APPROVAL OF APPLICATION OR RECERT. The following may also be included in the application packet or handed out at the interview as appropriate: Combined Six-Month Report (CSR) (DHS-5576) (PDF). To meet mandated reporter duties, an oral report may be made 24 hours a day, seven days a week, by calling the Minnesota Adult Abuse Reporting Center at 1-844-880-1574. It explains what needs to be reported. Your notice will say one of the following: You have 45 days from the date printed on your renewal to return your form. You must report all changes on your renewal form. A driver's license will not be issued until a satisfactory report is submitted. 715 11th Street N. Suite 502. Report all changes, including the following: If you do not know whether a change is important to your eligibility, report it and let your worker decide. Examples of Change that Require Reporting If you receive cash or medical assistance, you must report any change that affects your benefits. This page provides a list of frequently used DHS forms referenced in the CBSM. Referral to Support and Collections (DHS-3163B) (PDF). Read the answers to frequently asked questions about renewing MinnesotaCare coverage to help complete the renewal form and save yourself time and phone calls. ApplyMN applicants have access to required forms for the program(s) for which they applied. Minnesotas Diversionary Work Program (DHS-4034) (PDF). 325L.07) Forms. For all applicants: Supplemental Nutrition Assistance Program Reporting Responsibilities (DHS-2625) (PDF). Fire/Storm Drills. All MinnesotaCare members must verify that they remain eligible for MinnesotaCare by the end of the year. You do not need to do anything until you get this notice. SERV. SOCIAL SERVICES BLOCK GRANT (SSBG) hs-3130 Abuse Reporting Log - instructions hs-3109 SSBG Change in Circumstances - instructions hs-3115 SSBG Service Proposal - instructions PARENT/GUARD. Facilities and services licensed under the Human Services Licensing Act MS 245A are required to have policies and procedures related to reporting suspected or alleged maltreatment (MS 245A.65 and MS 626.557, subdivision 4a).. 0026.30 - NOTICE, DISQUALIFICATION OF AUTHORIZED REP. 0026.33 - NOTICE, DENYING GOOD CAUSE FOR IV-D NON-COOP, 0026.39 - NOTICE OF OVERPAYMENT AND RECOUPMENT, 0026.42 - NOTICE OF INCOMPLETE OR MISSING REPORT FORM, 0026.51 - NOTICES - CHEMICAL USE ASSESSMENT, 0027.12.03 - APPEAL HEARING EXPENSE REIMBURSEMENT, 0028.03 - COUNTY AGENCY EMPL. Your notice will say one of the following: You will have 45 days from the date printed on your renewal to return your form. Human Services, State Appeals Office, PO Box 64941, St. Paul, MN 55164-0941. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a handwritten signature. MN. COVID-19 reporting at DHS-operated treatment facilities, P-EBT children served, by county of residence, Provider alert survey for critical COVID-19 pressures, Temporary changes to public assistance programs during health emergency, Temporary changes to public assistance programs during health emergency - HMN, Temporary changes to public assistance programs during health emergency - RUS, Temporary changes to public assistance programs during health emergency - SOM, Temporary changes to public assistance programs during health emergency - SPA, Temporary changes to public assistance programs during health emergency - VIE, SNAP E and T Supplemental Nutrition Assistance Program, SNAP Supplemental Nutrition Assistance Program, SNAP frequently asked questions for seniors, farmers, immigrants, Contact the Ombudsman for Public Managed Health Care Programs, County and tribal directory for Minnesota Health Care Programs, Health plan member services phone numbers, MHCP Member Help Desk contact information, MinnesotaCare phone numbers and addresses, Applying for Medical Assistance (MA) or MinnesotaCare, MinnesotaCare eligibility for DACA grantees, Find a doctor or other health care provider, Health care coverage for adults without children, Health care coverage for people who are noncitizens, Health care coverage for people age 19 or 20, Health care coverage for people who need nursing home care, Health plan appeals, state appeals (state fair hearings), and grievances, How much does Minnesota Health Care Programs coverage cost, How other health insurance may affect eligibility for Medical Assistance or MinnesotaCare, Medical Assistance (MA) coverage for home and community based services through a waiver program, Medical Assistance for Breast or Cervical Cancer, New Applicants for Medical Assistance (MA) and MinnesotaCare, Ombudsman for Public Managed Health Care Programs, Options for resolving problems with health care services or bills, Renewing eligibility and reporting changes for Minnesota Health Care Programs, Resolving problems if you are not in a health plan, Resources for MHCP members who get care through a health plan, Minnesota Health Care Programs member notices, Printable application forms for health care programs, Adult Mental Health Residential Treatment Services, Adult Rehabilitative Mental Health Services, Adult mental health crisis response phone numbers, Alcohol, drugs and addictions: frequently asked questions, Substance abuse help paying for treatment, Alcohol, drugs and addictions: web resources, Egrifta fee for service prior authorization criteria, HIV: dental services covered by Program HH, Minnesota HIV AIDS program income guidelines, Program HH ADAP Drug Formulary by Alphabetical Order, Program HH Medication Program (ADAP) Formulary, Case management frequently asked questions, Dental program frequently asked questions, General Program HH frequently asked questions, Frequently asked questions about medication therapy, Video relay service and video remote interpreting, Communication Access Realtime Translation (CART) providers, Deaf and hard of hearing publications and reports, Frequently asked questions about Deaf-Blindness, Schools and programs for deaf and hard of hearing students, Minnesota State Operated Community Services Day Training and Habilitation sites and services, Child and Adolescent Behavioral Health Services.
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