DHS-3876-ENG (Minnesota Health Care Programs Application for

DHS-3876-ENG 11-19

MINNESOTA HEALTH CARE PROGRAMS (MHCP)

Application for Certain Populations

■

What is this application for?

Use this application if everyone in the household who wants to apply for health care coverage meets at

least one of these criteria:

• Is 65 years old or older

• Is blind or has a disability

• Is only requesting help with Medicare costs

• Is 21 years old or older, has no dependents, and has Medicare coverage

• Receives Supplemental Security Income (SSI)

• Is applying for Medical Assistance for Employed Persons with Disabilities (MA-EPD)

Use other applications for these purposes:

• If you are a person who lives in or may need to move to a nursing home, use the Minnesota Health Care

Programs Application for Medical Assistance for Long-Term-Care Services (MA-LTC) (DHS-3531).

• If you have a disability or are 65 years old or older and would like services to help you stay in your home,

use the Minnesota Health Care Programs Application for Medical Assistance for Long-Term-Care Services

(MA-LTC) (DHS-3531). Also ask your county or tribal agency about a long-term-care consultation.

People who don't meet any of these criteria should apply for health care coverage through MNsure,

Minnesota's health insurance marketplace. These include adults who are applying for coverage and have

dependents under the age of 19, even if the adults otherwise meet the criteria for using this application.

Use the online application at www.mnsure.org, or the Application for Health Coverage and Help Paying

Costs (DHS-6696). Individual members of the household who are 65 years old or older, are blind, have a

disability, or need access to home and community-based services will then receive a referral with a

supplemental form to complete.

You can find these applications on the web at https://mn.gov/dhs/health-care/paper-applications/ or have

one mailed to you by calling your county or tribal agency. The phone numbers are listed in Attachment C.

■

What do I need to do with this form?

1. Read the Notice of Privacy Practices and Notice of Rights and Responsibilities in Attachment A. Tear

them off and keep them.

2. Answer all questions on the application. If you need more space, write the number of the question and

the answer on a separate piece of paper. Include it with the application.

3. Sign and date the application.

4. Attach proofs. Send copies of proofs. Do not send original documents.

5. Mail or take the application to your county or tribal agency. The addresses are listed in Attachment C.

Send in your application right away even if you do not have all proofs. We will contact you if we need

more information.

■

Questions?

If you have questions or need help, call your county or tribal agency. The phone numbers are listed in

Attachment C. If you are 60 years old or older, you can also call the Senior LinkAge Line® at 800-333-2433. If

you have a disability, you can also call Disability Hub MN™ at 866-333-2466.

The information on this page can help you decide whether you want to apply for

Medical Assistance, Medicare Savings Programs, or both.

Medical Assistance

• Coverage can begin three months before the month

we get your application.

• Most health care services are covered, including

doctor visits, lab and x-ray services, prescriptions,

and hospital stays.

• Income limits (the amount of money you can have

and still be eligible) may be lower than for a

Medicare Savings Program.

• You may have copays for certain services.

• You can have other health insurance, even if it is

through an employer. Help with payment of other

health insurance may be possible.

• A claim may be placed against your estate for certain

benefits you receive from this program.

• You may be required to choose a health plan and

get all your health care services from providers in

that plan.

Medical Assistance for Employed Persons with

Disabilities (MA-EPD)

• If you have a disability and work, you may be eligible

for MA-EPD.

• To be eligible for MA-EPD, applicants 65 years old or

older must have been determined disabled before

age 65.

• MA-EPD has unique financial eligibility policies that

may be beneficial for people nearing age 63.

• To be eligible, you must have earnings and pay FICA

taxes.

• You must pay a monthly premium. The premium

may cost less than other types of health care

coverage.

• If you have retirement assets, you can keep and

accumulate more of those assets.

• Contact Disability Hub MN at 866-333-2466 for help

deciding the best program to meet your health care

needs.

Medicare Savings Programs

• These programs help pay for some Medicare costs.

Three programs all pay for Medicare Part B

premiums: Qualified Medicare Beneficiary (QMB),

Specified Low-Income Medicare Beneficiary (SLMB),

and Qualified Individual (QI).

• Payment of your Part B premiums can begin three

months before the month we get your application.

• If you have income at or below 100 percent of the

federal poverty guidelines (FPG), you may qualify for

payment of both Medicare Part A and Part B

premiums, and for payment of your Medicare

deductibles and copays.

• If you are a qualified working and disabled individual

with income no greater than 200 percent of the FPG,

you qualify for the Qualified Working Disabled

(QWD) program, which pays for the Medicare Part A

premium.

• These programs allow you to have more assets than

may be allowed by the Medical Assistance program.

• No claim is placed against your estate for benefits

received from this program.

• You may be eligible for both Medical Assistance and

the QMB, SLMB or QWD Medicare Savings Program.

Medical Assistance and Medicare Savings

Programs

• You may be eligible for both Medical Assistance and

a Medicare Savings Program.

• Medicare Savings Programs pay only some expenses

related to Medicare coverage.

• Medical Assistance members may be subject to

Minnesota's estate recovery and lien program, but

only for Medical Assistance services.

For more information:

• Call your county or tribal agency. The phone

numbers are listed in Attachment C.

• Go to https://mn.gov/dhs/people-we-serve/ for

more information.

DHS-3876-ENG 11-19

Page 1 of 12

MINNESOTA HEALTH CARE PROGRAMS (MHCP)

Application for Certain Populations

Office Use Only

DATE RECEIVED CASE NUMBER WORKER NUMBER

• Answer all questions the best you can.

• Return the form right away.

• We will contact you if we need more information.

1. If you want to apply for only a Medicare Savings Program, check the following box.

I want to apply for only Medicare Savings Programs. I do not want to apply for other health care programs.

Information about the person applying

FIRST NAME MI LAST NAME DATE OF BIRTH

GENDER

Male Female

MARITAL STATUS

Legally separated Divorced Never married Married Widowed

Do you have a Social Security number (SSN)*?

Yes No

*See the Notice of Privacy Practices and Notice of

Rights and Responsibilities (Attachment A) for

information about Social Security numbers.

IF YES, WHAT IS YOUR SSN? IF NO, HAVE YOU APPLIED FOR AN SSN?

Yes No

IF YOU HAVE NOT APPLIED, WHY NOT? (Choose a reason code from the list on Attachment B)

Do you have a guardian or conservator?

Yes – fill in the following No

NAME OF GUARDIAN OR CONSERVATOR PHONE NUMBER

STREET ADDRESS CITY STATE ZIP CODE

Have you ever been in the U.S. military?

Yes No

Are you a student?

Yes No

Are you blind?

Yes No

Do you have a physical, mental, or emotional health

condition that limits your activities (like bathing, dressing,

daily chores, etc.)?

Yes No

If yes, have you been determined disabled by the Social

Security Administration (SSA) or the State Medical Review

Team (SMRT)?

Yes No

Do you need help staying in your home or help paying for care in a long-term-care facility, such as a nursing home?

Yes No

Are you pregnant?

Yes No Not applicable

IF YES, HOW MANY BABIES ARE EXPECTED? DUE DATE (MM/DD/YYYY)

What language do you speak most of the time?

Do you need an interpreter?

Yes No

OPTIONAL

INFORMATION

→

RACE (Choose one or more race codes from the list on Attachment B, or write in your race if it is not on the list.)

Clear Form

Page 2 of 12 DHS-3876-ENG 11-19

2. If you or anyone in your family is an American Indian or Alaska Native, some income and

assets might not count toward your eligibility and you might not be required to pay

premiums or copays. Do you want to apply for these exceptions?

Yes – you need to complete and include Appendix A No

3. Address and phone number

STREET ADDRESS WHERE YOU ARE CURRENTLY LIVING CITY STATE ZIP CODE COUNTY

MAILING STREET ADDRESS (if different) CITY STATE ZIP CODE COUNTY

PHONE NUMBER

Do you plan to make Minnesota your

home?

Yes No

Do you currently have medical benefits from another state?

Yes No

OPTIONAL INFORMATION ↓

What is your living situation? (choose one)

I have my own housing (rent, pay a mortgage or share housing costs with a roommate).

I live with family or friends because of economic hardship.

I live in an emergency shelter.

I live in a service provider's housing (foster home, group home or assisted living).

I live in a hospital, nursing home, treatment facility or detox center.

I live in a jail, prison or juvenile detention facility.

I live in a hotel or motel.

I live in a place not meant for housing (anywhere outside, a vehicle, an abandoned building, a bus or train station, or

an airport).

Unknown

I decline to answer.

In which county do you live?

4. Others living with you

(List your spouse, parents or guardians of children under 21, stepparents, children and stepchildren living in your home.

Include people who are living away from home for a short time.) Do not include yourself. For people not seeking health

care coverage, only name, date of birth and relationship are required.

Person 1

Does this person want health care coverage?

Yes No

FIRST NAME MI LAST NAME DATE OF BIRTH

RELATIONSHIP TO YOU GENDER

Male Female

MARITAL STATUS

Legally separated Divorced Never married Married Widowed

Does this person have a Social Security

number (SSN)*?

Yes No

*See the Notice of Privacy Practices and Notice of

Rights and Responsibilities (Attachment A) for

information about Social Security numbers.

IF YES, WHAT IS THE SSN? IF NO, HAS THIS PERSON APPLIED FOR AN SSN?

Yes No

IF PERSON HAS NOT APPLIED, WHY NOT? (Choose a reason code from the list on Attachment B)

Does this person plan to make Minnesota his or her home?

Yes No

Is this person a student?

Yes No

Is this person blind?

Yes No

Page 3 of 12 DHS-3876-ENG 11-19

Does this person have a physical, mental, or emotional health

condition that limits activities (like bathing, dressing, daily

chores, etc.)?

Yes No

If yes, has this person been determined disabled by the Social

Security Administration (SSA) or the State Medical Review

Team (SMRT)?

Yes No

Does this person need help staying in his or her home or help paying for care in a long-term-care facility, such as a nursing

home?

Yes No

Has this person ever been in the U.S. military?

Yes No

Does this person currently have medical benefits from another state?

Yes No

Is this person pregnant?

Yes No Not applicable

IF YES, HOW MANY BABIES ARE EXPECTED? DUE DATE (MM/DD/YYYY)

OPTIONAL

INFORMATION

→

RACE (Choose one or more race codes from the list on Attachment B, or write in this person's race if it is not on the list.)

Person 2

Does this person want health care coverage?

Yes No

FIRST NAME MI LAST NAME DATE OF BIRTH

RELATIONSHIP TO YOU GENDER

Male Female

MARITAL STATUS

Legally separated Divorced Never married Married Widowed

Does this person have a Social Security

number (SSN)*?

Yes No

*See the Notice of Privacy Practices and Notice of

Rights and Responsibilities (Attachment A) for

information about Social Security numbers.

IF YES, WHAT IS THE SSN? IF NO, HAS THIS PERSON APPLIED FOR AN SSN?

Yes No

IF PERSON HAS NOT APPLIED, WHY NOT? (Choose a reason code from the list on Attachment B)

Does this person plan to make Minnesota his or her home?

Yes No

Is this person a student?

Yes No

Is this person blind?

Yes No

Does this person have a physical, mental, or emotional health

condition that limits activities (like bathing, dressing, daily

chores, etc.)?

Yes No

If yes, has this person been determined disabled by the Social

Security Administration (SSA) or the State Medical Review

Team (SMRT)?

Yes No

Does this person need help staying in his or her home or help paying for care in a long-term-care facility, such as a nursing

home?

Yes No

Has this person ever been in the U.S. military?

Yes No

Does this person currently have medical benefits from another state?

Yes No

Is this person pregnant?

Yes No Not applicable

IF YES, HOW MANY BABIES ARE EXPECTED? DUE DATE (MM/DD/YYYY)

OPTIONAL

INFORMATION

→

RACE (Choose one or more race codes from the list on Attachment B, or write in this person's race if it is not on the list.)

5. Is anyone listed in Question 4 living away from home for a short time?

Yes – fill in the information No

FIRST NAME MI LAST NAME DATE LEFT DATE EXPECTED TO RETURN

REASON FOR NOT LIVING AT HOME

Page 4 of 12 DHS-3876-ENG 11-19

6. Is everyone applying a U.S. citizen or U.S. national?

Yes No – fill in the information

Person 1

NAME

What is this person's current immigration status? (Choose a status code from the list on Attachment B, or write in the status below if it is not on the list.)

a. IMMIGRATION DOCUMENT TYPE b. ALIEN ID NUMBER c. CARD NUMBER

d. Did this person enter the United States

before August 22, 1996?

Yes No

e. Has this person lived in the United States for five years or more in a qualified

status? (See Attachment B to determine whether a status is qualified.)

Yes No

f. DATE OF ENTRY (MM/DD/YYYY)

g. Does this person have a sponsor?

Yes No

h. Is this person, or the person's spouse or parent, a veteran

or active-duty member of the military?

Yes No

i. Does this person want help paying for a medical

emergency?

Yes No

j. Is this person getting services from the Center for Victims

of Torture?

Yes No

k. Did this person ever have an immigration status different from his or her current status (example, refugee or asylee)?

Yes – fill in the following No

What is this person's previous immigration status? (Choose a status code from the list on Attachment B, or write in the status below if it is not on the list.)

ORIGINAL DATE OF ENTRY (MM/DD/YYYY)

Person 2

NAME

What is this person's current immigration status? (Choose a status code from the list on Attachment B, or write in the status below if it is not on the list.)

a. IMMIGRATION DOCUMENT TYPE b. ALIEN ID NUMBER c. CARD NUMBER

d. Did this person enter the United States

before August 22, 1996?

Yes No

e. Has this person lived in the United States for five years or more in a qualified

status? (See Attachment B to determine whether a status is qualified.)

Yes No

f. DATE OF ENTRY (MM/DD/YYYY)

g. Does this person have a sponsor?

Yes No

h. Is this person, or the person's spouse or parent, a veteran

or active-duty member of the military?

Yes No

i. Does this person want help paying for a medical

emergency?

Yes No

j. Is this person getting services from the Center for Victims

of Torture?

Yes No

k. Did this person ever have an immigration status different from his or her current status (example, refugee or asylee)?

Yes – fill in the following No

What is this person's previous immigration status? (Choose a status code from the list on Attachment B, or write in the status below if it is not on the list.)

ORIGINAL DATE OF ENTRY (MM/DD/YYYY)

Page 5 of 12 DHS-3876-ENG 11-19

7. Do you want someone to act on your behalf as an authorized representative?

Yes – complete Appendix B No

(You can give a trusted person permission to talk about this application with us, see your information and act for you on matters related to

this application, including getting information about your application and signing your application on your behalf.)

8. Does anyone applying for health care on this application want help from MA to pay for

medical bills from the past three months?

(The start date for MA can go back up to three months. You must have medical bills and meet the MA requirements for each month you

want coverage.)

Yes – fill in the information No

WHICH PERSON? (First, MI, Last)

HOW MANY MONTHS?

One Two Three

WHICH PERSON? (First, MI, Last)

HOW MANY MONTHS?

One Two Three

You must provide proof of your medical expenses, income and assets in each of the months for which you are requesting

coverage. Refer to the types of proof listed after each of the following questions for examples of acceptable proof for the income

and assets you had.

9. Is anyone self-employed, or does anyone expect to be self-employed next month?

Yes – fill in the information No

Name Type of work Monthly income Monthly expenses

Start date

(MM/DD/YYYY)

$ $

You must provide proof of this income. Proof may be most recent income tax returns and all related schedules, or business

records if taxes are not filed.

10. Is anyone working, or does anyone expect to work in the next month?

Yes – fill in the information No

Person 1

NAME

EMPLOYER NAME START DATE (MM/DD/YYYY)

Is this job seasonal?

Yes No

Has this job ended?

Yes No

IF YES, END DATE (MM/DD/YYYY)

Wages and tips before taxes (Choose one and fill in the dollar amount and your hours per week.)

Hourly

Weekly

Every two weeks

Twice a month

Monthly

Yearly

$ per hour

Hours per week:

Page 6 of 12 DHS-3876-ENG 11-19

Person 2

NAME

EMPLOYER NAME START DATE (MM/DD/YYYY)

Is this job seasonal?

Yes No

Has this job ended?

Yes No

IF YES, END DATE (MM/DD/YYYY)

Wages and tips before taxes (Choose one and fill in the dollar amount and your hours per week.)

Hourly

Weekly

Every two weeks

Twice a month

Monthly

Yearly

$ per hour

Hours per week:

You must provide proof of this income. Proof may be paystubs or a written statement of earnings from your employer if you do

not have paystubs.

11. Did anyone get money this month or does anyone expect to get money next month

from sources other than work?

Include: • Social Security • Child or spousal support • Unemployment • Interest

• Supplemental Security Income (SSI) • Workers' compensation • Veterans' benefits • Dividends

• Retirement or pension payments • Public assistance payments • Rental income • Trusts

• Payments from a contract for deed • Annuities • Any other payments

Yes – fill in the information No

Person 1

NAME

Type of income Amount How often received? Has this income ended?

Yes No

– END DATE:

Yes No

– END DATE:

Yes No

– END DATE:

Yes No

– END DATE:

Person 2

NAME

Type of income Amount How often received? Has this income ended?

Yes No

– END DATE:

Yes No

– END DATE:

Yes No

– END DATE:

Yes No

– END DATE:

You must provide proof of this income. Proof may be award letters, copies of checks, tax forms, court orders, or other

documents.

Page 7 of 12 DHS-3876-ENG 11-19

12. Is anyone in the household blind, or does anyone have a disability?

Yes – fill in the information No

Name Does this person have work expenses? If yes, type of expenses Monthly amount

Yes No Not applicable $

You must provide proof of these work expenses.

Questions 13–24 are for only those household members who are 21 years old or older.

13. How much cash do you or your spouse have on hand, in a safety

deposit box, at home and at the facility where you live?

14. Do you or your spouse have savings or checking accounts, money market accounts or

certificates of deposit?

Yes – fill in the information No

Owner name(s) Type of account Bank name and address Account number

You must provide proof of these assets. Proof may be recent account statements or a written statement from your bank, credit

union, or other financial institution showing the current balance or value of accounts.

15. Do you or your spouse have stocks, bonds or retirement accounts?

Yes – fill in the information No

Owner name(s) Type of investment Company or bank name and address Account number

You must provide proof of these assets. Proof may be copies of bonds, stock ownership, retirement accounts, or documents

showing current loan balance owed against the asset.

Page 8 of 12 DHS-3876-ENG 11-19

16. Do you or your spouse own or co-own houses, condominiums, summer or winter

homes, cabins, mobile homes, time-shares, rental properties, any other real estate, or

life estate interests or remainder interests in real property?

Yes – fill in the information No

Owner name(s) Type of property Property address

Do you or your spouse

live here all year?

Yes No

You must provide proof of these assets. Proof may be real property tax statements, warranty deeds, quit claim deeds, life estate

or other real property agreements or documents showing the amounts owed against the property.

17. Do you or your spouse own or co-own promissory notes, contracts for deed or other

property agreements?

Yes – fill in the information No

Owner name(s) Type of property

You must provide proof of these assets. Proof may be copies of the contract for deed, mortgage, loan contract, or

promissory note.

18. Do you or your spouse have any vehicles in your name?

Include cars, trucks, vans, motorcycles, motor homes, campers, boats, snowmobiles, all-terrain vehicles, etc.

Yes – fill in the information No

Owner name(s) Type of vehicle Year, make, model

You must provide proof of these asset. Proof may be copies of your vehicle title.

Page 9 of 12 DHS-3876-ENG 11-19

19. Do you or your spouse have an interest in a trust or annuity?

Yes – fill in the information No

Owner name(s) Type

You must provide proof of these assets. Proof may be copies of the annuity contract, other documents showing the value of

the annuity or copies of the entire trust document.

20. Do you or your spouse have life insurance?

Yes – fill in the information No

Owner name(s) Policy number Insurance company name and address

You must provide proof of the current cash surrender value of all policies. You must provide copies of the life

insurance policy.

21. Do you or your spouse have a prepaid burial account or burial trust?

Include revocable and irrevocable accounts, insurance-funded burials, annuity-funded burials, Cremation Society

agreements, burial spaces, burial space items and other funds designated for burial.

Yes – fill in the information No

Owner name(s) Type of burial asset Company or bank name and address

You must provide proof of these assets. Proof may be copies of the life insurance policy, burial contracts or other documents

showing the current value of the assets.

22. Do you or your spouse have assets currently used for self-employment or in a business

in which you or your spouse has an interest?

Yes – fill in the information No

Owner name(s) Type of asset

You must provide proof of these assets. Proof may be current tax documents, business ledgers, or account statements.

Page 10 of 12 DHS-3876-ENG 11-19

23. Do you or your spouse own or co-own any other assets you have not listed?

Yes – fill in the information No

Owner name(s) Type of asset

You must provide proof of these assets.

24. Do you or your spouse live in a continuing care retirement community?

Yes No

You must provide proof of the entrance fee.

25. Is anyone applying for health care on this application getting medical care for an

accident or injury that happened in the last six years?

Yes – fill in the information No

Name Type of accident of injury

Date happened

(MM/DD/YYYY)

Is there a lawsuit?

Yes No

You must provide proof of your medical injury. Proof may be information about your injury; third-party insurance claims,

including automobile insurance claims; or workers' compensation payments or benefits.

26. Does anyone have Medicare, other health coverage or long-term-care insurance now,

or has anyone had coverage in the last three months?

Yes – fill in the information No

Person 1

NAME

COVERAGE TYPES

Medicare Medicare supplemental policy Medical insurance Hospital only HMO Prescription drug

Dental Vision Long-term care Other

(list type)

POLICYHOLDER'S NAME INSURANCE COMPANY NAME START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY)

POLICY NUMBER LIST EVERYONE WHO IS COVERED BY THIS POLICY MONTHLY PREMIUM

Is this health insurance through an employer or union?

Yes No

Page 11 of 12 DHS-3876-ENG 11-19

Person 2

NAME

COVERAGE TYPES

Medicare Medicare supplemental policy Medical insurance Hospital only HMO Prescription drug

Dental Vision Long-term care Other

(list type)

POLICYHOLDER'S NAME INSURANCE COMPANY NAME START DATE (MM/DD/YYYY) END DATE (MM/DD/YYYY)

POLICY NUMBER LIST EVERYONE WHO IS COVERED BY THIS POLICY MONTHLY PREMIUM

Is this health insurance through an employer or union?

Yes No

You must provide proof of your health care coverage. Proof may be front and back copies of your health insurance cards,

documentation of monthly premium amounts, written documentation of coverage from the health insurance provider or

copies of paid medical bills.

WORKER NOTES

Page 12 of 12 DHS-3876-ENG 11-19

DHS-5239D-ENG 10-19

Signature Page

(Effective Date: October 2019)

Read the following information and sign.

Please complete this page and read the attached Notice of Privacy Practices and Notice of

Rights and Responsibilities (Attachment A) before signing this page.

By signing this page:

I received and reviewed the Notice of Privacy Practices and the Notice of Rights and Responsibilities (Attachment A).

I know that I must report changes to the information listed on this application.

I declare under the penalties of perjury that this application has been examined by me and to the best of my

knowledge is a true and correct statement of every material point. I understand that a person convicted of perjury

may be sentenced to imprisonment of not more than five years or payment of a fine of not more than $10,000, or

both. I understand that there may be other penalties for not telling the truth.

Additional agreements for Medical Assistance

I consent to the release of my Minnesota Health Care Programs health records to the parties listed in the Consent for

Sharing of Medical Information section of the Notice of Rights and Responsibilities.

• I give the Medical Assistance agency our rights to pursue and get any money from other health insurance, legal

settlements, or other third parties.

• I have read and understand that the state may claim repayment for the cost of medical care, or the cost of the

premiums paid for care, from my estate or my spouse's estate.

• I understand that my information, and information about me shared from third parties, will be shared for fraud

prevention investigations as stated in the Notice of Privacy Practices.

• If I am a parent that is eligible for Medical Assistance, I understand I may be asked to cooperate with the agency that

collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me

or my children, I can tell the agency, and I may not have to cooperate. I give to the Medical Assistance agency the

rights to medical support paid for my children.

YOUR SIGNATURE DATE

AUTHORIZED REPRESENTATIVE SIGNATURE, IF APPLICABLE DATE

Submit your completed and signed application

Submit your completed and signed application and your proofs in one of these three ways:

• Fax your application for faster processing.

• Mail your application.

• Submit your application in person.

Mail, fax, or bring your application and proofs to your county or tribal agency. The addresses and fax numbers are

listed in Attachment C. Send copies of proofs. Do not send original documents. Note: Ask your worker if you need

help getting proofs. Some required proofs, such as certification of disability, citizenship and identity, will first be

requested electronically from other government agencies.

If you want to register to vote in Minnesota, you can complete a voter registration form at sos.state.mn.us.

Attachment A

Attachment - Keep this page.

DHS-4839E-ENG 11-18

MINNESOTA DEPARTMENT OF HUMAN SERVICES

Notice of Privacy Practices and

Notice of Rights and Responsibilities

(Effective Date: November 2018)

Notice of Privacy Practices

This part of the notice describes how private or confidential information about you may be used and disclosed.

Please review it carefully.

Why do we ask for this information?

• To tell you apart from other people with the same or

similar name

• To decide what you are eligible for

• To help you get medical and mental health services and

decide whether you can pay for some services

• To decide whether you or your family need protective

services

• To decide about out-of-home care and in-home care for

you or your children

• To make reports, do research, do audits, and evaluate our

programs

• To investigate reports of people that may lie about the

help they need or to get assistance they may not be

entitled to receive

• To collect money from other agencies, like insurance

companies, if they should pay for your care

• To collect money from the state or federal government

for help we give you

Why do we ask you for your Social Security

number?

We need your Social Security number (SSN) to give you

Medical Assistance (MA), some kinds of financial help, and

child support enforcement services (42 USC 666; Minn. Stat.

256L.04, subd. 1a; 42 CFR 435.910).

We also need your SSN to verify identity and prevent

duplication of state and federal benefits. Additionally, your

SSN is used to conduct computer data matches with our

partner nonprofit and private agencies to verify income,

resources, and other information that may affect your

eligibility or benefits.

You do not have to give us the SSN for people in your home

who are not applying for coverage. You also do not have to

give us your SSN:

• If you have religious objections

• If you are not a U.S. citizen and are applying for

Emergency Medical Assistance only

• If you are from another country, are in the U.S. on a

temporary basis, and do not have permission from the

U.S. Citizenship and Immigration Services (USCIS) to live

in the U.S. permanently

• If you are living in the U.S. without the knowledge or

approval of the USCIS

Why do we ask you for your financial

information?

We use this information only for the purposes authorized by

law, such as verifying eligibility or determining the amount

of a premium. We will not share this information with any

other person or entity.

Do you have to answer the questions

we ask?

You do not have to give us your personal information.

Without the information, we may not be able to help you. If

you give us wrong information on purpose, you could be

investigated and then charged with a crime.

With whom may we share information?

We will share information about you only as needed and as

allowed or required by law. We may share your information

with the following agencies or people who need the

information to do their jobs:

• Employees or volunteers with other state, county, local,

federal, and partner nonprofit and private agencies

• Researchers, auditors, investigators, and others that do

quality-of-care reviews and studies or begin prosecutions

or legal actions related to managing the human services

programs

• Court officials, county attorneys, attorneys general, other

law enforcement officials, child support officials, child

protection and fraud investigators, and fraud prevention

investigators

• Human services offices, including child support

enforcement offices

• Governmental agencies in other states administering

public benefits programs

• Health care providers, including mental health agencies

and drug and alcohol treatment facilities

• Health care insurers, health care agencies, managed care

organizations and others that pay for your care

• Guardians, conservators or people with power of attorney

who are authorized representatives

• Coroners and medical investigators if you die and they

investigate your death

• Credit bureaus, creditors or collection agencies if you do

not pay fees you owe to us for services, in limited situations

• Certified application counselors, in-person assisters, and

navigators and anyone else the law says we must or can

give the information to

Attachment - Keep this page.

What are our responsibilities?

• We must protect the privacy of your personal, health care

and other private information according to the terms of

this notice.

• We may not use your information for reasons other than

the reasons listed on this form or share your information

with people and agencies other than those listed on this

form unless you tell us in writing that we can.

• We will not sell any data collected, created, or maintained

as part of this application.

• We must follow the terms of this notice and give you a

copy of it, but we may change our privacy policy. Those

changes will apply to all information we have about you.

The new notice will be available on request, and we will

put changes to it on our website at https://

edocs.dhs.state.mn.us/lfserver/Public/DHS-4839E-ENG.

• The law requires us to keep your private information

private and secure.

• If something happens that causes your private

information to no longer be private and secure, we will let

you know right away.

This part of the notice describes how medical

information about you may be used and disclosed

and how you can get access to this information.

Please review it carefully.

We can use and share your health care

information to

• Help manage the health care treatment you receive

• We can use your health information and share it with

professionals who are treating you. Example: A doctor

sends us information about your diagnosis and treatment

plan so we can arrange additional services.

• We can also share your information with guardians,

conservators or people with power of attorney who are

authorized representatives

• Run our organization

• We can use and share your information to run our

organization and contact you when necessary. This

includes sharing your information with employees or

volunteers with other state, county, local, federal, and

partner nonprofit and private agencies, including child

support offices.

• We can share your information with these people and

groups:

º Auditors, investigators, and others that do quality-of-

care reviews and studies

º Credit bureaus, creditors or collection agencies if you

do not pay fees you owe to us for services, in limited

situations

º Certified application counselors, in-person assisters,

and navigators and anyone else the law says we must

or can give the information to

• We are not allowed to use genetic information to

decide whether we will give you coverage and the price

of that coverage. This does not apply to long-term-care

plans. Example: We use health information about you to

develop better services for you.

• Pay for your health services

• We can use and share your health information as we

pay for your health services. Example: We share

information about you with your dental plan to

coordinate payment for your dental work.

• Help with public health and safety issues

• We can share health information about you for

purposes like these:

º Preventing disease

º Helping with product recalls

º Reporting adverse reactions to medications

º Reporting suspected abuse, neglect, or domestic

violence

º Preventing or reducing a serious threat to anyone's

health or safety

• Do research

• We can use or share your information for health research.

• Comply with the law

• We will share information about you if state or federal

laws require it. This includes sharing information with the

Department of Health and Human Services if it wants to

see that we're complying with federal privacy law.

• Respond to organ and tissue donation requests and

work with a medical examiner or funeral director

• We can share health information about you with organ

procurement organizations.

• We can share health information with a coroner, medical

examiner, or funeral director when a person dies.

• Address workers' compensation, law enforcement,

and other government requests

• For workers' compensation claims

• For law enforcement purposes or with a law

enforcement official

• With health oversight agencies for activities authorized

by law

• With governmental agencies in other states

administering public benefits programs

• For special government functions, such as military,

national security, and presidential protective services

• Respond to lawsuits and legal actions

• We can share health information about you in response

to a court order. We may share the information with

court officials, county attorneys, attorneys general,

other law enforcement officials, child support officials,

child protection and fraud investigators, and fraud

prevention investigators.

What are your rights regarding the

information we have about you?

Get a copy of health and claims records

• You and people you have given permission to may see

and copy private information we have about you, such as

health and claims records. You may have to pay for the

copies.

• You can choose someone to act for you with a medical

power of attorney or as a legal guardian. That person can

exercise your rights and make choices about your

information.

Attachment - Keep this page.

Ask us to correct health and claims records

• You may question whether the information we have

about you is correct. Send your concerns in writing. Tell

us why the information is wrong or not complete. Send

your own explanation of the information you do not

agree with. We will attach your explanation anytime

information is shared.

Request confidential communications

• You have the right to ask us in writing to share health

information with you in a certain way or in a certain place.

• We will consider all reasonable requests. We must say yes

if you tell us you would be in danger if we did not. For

example, you may ask us to send health information to

your work address instead of your home address. If we

find that your request is reasonable, we will grant it.

Ask us to limit what we use or share

• You can ask us not to use or share certain health

information for treatment, payment, or our operations.

We are not required to agree to your request and we may

say no if it would affect your care.

Get a list of those with whom we've shared information

• This list will not include disclosures for treatment,

payment, and health care operations. It will also not

include certain other disclosures, such as any you asked

us to make.

• We'll provide one list a year for free but will charge a

reasonable, cost-based fee if you ask for another one

within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even

if you have agreed to receive the notice electronically. We

will provide you with a paper copy promptly.

If you do not understand the information, ask your worker

to explain it to you. You may ask the Minnesota Department

of Human Services for another copy of this notice.

What are your choices?

For certain health information, you can tell us your choices

about what we share.

You have both the right and choice to tell us to:

• Share health information with your family, close friends,

or others involved in payment for your care

• Share information in a disaster relief situation

Tell us what you want us to do, and we will follow your

instructions. If you are not able to tell us your preference, for

example, if you are unconscious, we may go ahead and

share your information if we believe it is in your best

interest. We may also share your information when needed

to lessen a serious and imminent threat to health or safety.

What privacy rights do children have?

If you are under 18, when parental consent for medical

treatment is not required, information will be provided to

parents only when the medical provider believes that your

health is at risk if the information is not shared. Parents may

see other information about you and let others see this

information, unless you have asked that this information not

be shared with your parents. You must ask for this in writing

and say what information you do not want to share and

why. If the agency agrees that sharing the information is not

in your best interest, the information will not be shared with

your parents. If the agency does not agree, the information

may be shared with your parents if they ask for it.

What if you believe your privacy rights

have been violated?

You may complain if you believe your privacy rights have

been violated. You cannot be denied service or treated

badly because you have made a complaint. If you believe

that your medical privacy was violated by your doctor or

clinic, a health insurer, a health plan, or a pharmacy, you

may send a written complaint to either the county agency,

the organization or the federal civil rights office at:

U.S. Department of Health and Human Services

Office for Civil Rights, Region V

233 N. Michigan Avenue, Suite 240

Chicago, IL 60601

312-886-2359 (voice)

800-368-1019 (toll free)

800-537-7697 (TTY)

312-886-1807 (fax)

If you believe the Minnesota Department of Human Services

violated your privacy rights, you may also contact:

Minnesota Department of Human Services

Attn: Data Complaint

PO Box 64998

St. Paul, MN 55164-0998

Whom do you contact if you need more

information about privacy practices?

If you need more information about privacy practices, call

the Minnesota Health Care Programs (MHCP) Member Help

Desk at 800-657-3739 or 651-431-2670.

Attachment - Keep this page.

Notice of Rights and Responsibilities

Changes

If you have MA, you must report a change within 10 days

of the change happening. Call your county or tribal

agency to report the change.

If you do not report changes, you may have to pay money

back to the state or federal government for benefits that

you received but were not eligible for. If you are not sure

whether to report a change, call and explain what is

happening. Examples of changes you need to report

include the following:

Income changes when you

• Start a new job, change jobs or stop a job

• Start to get, or receive changes in the amount of, other

income like Social Security, other retirement income

and unemployment

Residence changes when you

• Move to a new address

Life changes in your household when someone

• Starts or stops other health insurance or Medicare

• Becomes pregnant or has a baby

• Moves in or out of your home

• Changes tax filing status

• Loses Minnesota residency

• Changes citizenship or lawful presence status

• Changes incarceration status

• Dies, gets married or gets a divorce

• Becomes disabled

Reviews

The state or federal agency's health care program auditors

may look at your case. They will review the information

you gave us and check to make sure we processed your

case correctly. They will let you know if they need to ask

you questions.

Consent for Sharing of Medical Information

In your application for Minnesota Health Care Program

coverage, you have given your written and signed consent

to the following agencies and people to share between

them medical information about you only for the limited

purposes indicated:

• Health providers, including health plans, insurance

agencies, Minnesota Health Care Programs, county

advocates, school districts, your county or state case

workers, and their contractors and subcontractors, for

these purposes:

• To determine who should pay for your health care

• To provide, manage and coordinate health care services

• All other agencies or people listed on this Notice of

Privacy Practices and Notice of Rights and

Responsibilities, for this purpose:

• To administer Minnesota Health Care Programs, pay for

services, and conduct research and investigations

This consent applies to medical information about your

minor children you applied for on this application.

You can stop this consent at any time by asking in writing

for it to end. The written notice to stop this consent will not

affect information the agency has already given to others.

This consent is good while you are enrolled in Minnesota

Health Care Programs, up to one year or longer if the law

permits.

However, it does not end after one year for records given to

consulting providers or for payment of your bills, fraud

investigations or quality-of-care review and studies.

An agency or person who gets your information through

this consent could give the information to others.

If you end this consent, you cannot enroll or stay enrolled in

Minnesota Health Care Programs.

Other Health Care

You and your household members enrolled in MA must tell

us about any other health insurance that you have or that is

available to you, including employer-sponsored coverage,

private health insurance, long-term-care insurance, and any

limited health coverage, such as dental or accident

coverage. You must tell us whether your employer offers

insurance and whether you accepted it.

You and your household members enrolled in MA may need

to accept and keep a health insurance policy when the

policy is found to be cost effective. If you have a good

reason for not doing that, you may ask the state to approve

the reason. If you do not give us information about your

health insurance policy, you may not get coverage.

You must also tell us when you become eligible for

Medicare. MA pays for the Medicare premiums of some low-

income people. Once you are eligible for Medicare Part B

and Part D, MA will no longer pay for services that could be

covered by a Medicare program.

MA Medical Support

If you are applying for yourself and your children and you

do not live with the other parent, the law says you may have

to give information to child support staff if both you and

your child are eligible for MA. This includes helping the state

prove who the father of your children is and helping the

state to get the other parent to help pay the children's

medical expenses. If you do not help child support staff,

your children will still get coverage, but your coverage will

end, unless you are pregnant.

If you are afraid the other parent may cause harm to you or

your child, you can give your county or tribal agency proof

to support your fears. The agency will review your proof and

tell you whether you still must give information to child

support staff.

Attachment - Keep this page.

Assignment of Medical Payments

By accepting MA, you give your rights to all medical

payments for yourself and anyone else you apply for to

the state of Minnesota. These include medical payments

from all other people or companies, including medical

support payments from an absent parent. This assignment

of medical payments begins as soon as health care

coverage starts. For MA for Long-Term Care, this includes

your right to support from your spouse under Minnesota

Statutes, section 256B.14, subdivision 3.

You also agree to help the state get paid back for medical

expenses that should have been paid by others. You may

not have to help the state if you have a good reason for

not helping and the state approves the reason.

MA Estate Claims and Liens

In certain circumstances, federal and state law require the

Minnesota Department of Human Services and local

agencies to recover costs that the MA program paid for its

members health care services. This recovery process is

done through Minnesota's MA estate recovery and lien

program.

If you are enrolled in MA when you are 55 years old or

older, then, after you die, Minnesota must try to recover

certain payments the MA program made for your health

care, including:

• Nursing home services

• Home and community-based services

• Related hospital and prescription drug costs

If you permanently live in a medical institution, Minnesota

must also try to recover the costs of all MA services you

receive at any age while living in a medical institution. If

you are permanently living in a medical institution and

you do not have a spouse or disabled child living on your

homesteaded real property, the state may file an MA lien

against your real property to recover MA costs before your

death. However, MA members who qualify for services

under modified adjusted gross income (MAGI) eligibility

criteria are not subject to recovery for services received

before the age of 55.

After you die, the state also may file a notice of potential

claim, which is a form of lien, against real property to

recover MA costs. Liens to recover MA costs may be filed

against the following:

• Your life estate or joint tenancy interest in real property

• Your real property that you own solely

• Your real property that you own with someone else

Minnesota cannot start recovery of these costs while your

spouse is still living or if you have a child under 21 years

old or a child who is permanently disabled. Once your

spouse dies, Minnesota must try to recover your MA costs

from your spouse's estate. However, recovery is further

delayed if you still have a child who is under 21 or

permanently disabled.

Your children do not have to use their assets to reimburse

the state for any MA services you received.

You have the right to speak with a legal-aid group or a

private attorney if you have specific questions about how

MA estate recovery and liens may affect your circumstance

and estate planning. The Minnesota Department of Human

Services cannot provide you with legal advice. For more

information, go to http://mn.gov/dhs/ma-estate-recovery/.

You Have the Right to Ask for a Hearing

If you feel your health care eligibility or benefits are wrong or

your application was not processed correctly, you may ask for

an appeal hearing. By requesting an appeal hearing, you are

requesting a fair review of your case. You can represent

yourself or use an attorney, advocate, authorized

representative, relative, friend or other person. You will find

specific appeal instructions on all eligibility notices that you

receive. Learn more about the appeals process and how to

ask for a hearing at www.dhs.state.mn.us/appeals/faqs.

You can complete and submit an appeal request online at

https://edocs.dhs.state.mn.us/lfserver/Public/DHS-0033-ENG.

You can also print the form that is available at the address

above and submit the completed form by fax to

651-431-7523 or by mail to this address:

Minnesota Department of Human Services

Appeals Division

PO Box 64941

St. Paul, MN 55164-0941

Immigration

Immigration information you give to us is private. We use it to

see whether you can get coverage. We share it only when the

law allows it or requires it, such as to verify identity. In most

cases, applying will not affect your immigration status unless

you are applying for payment of long-term-care services.

You do not have to give us your immigration information if

you are a pregnant woman living in the United States

without the knowledge or approval of the United States

Citizenship and Immigration Services (USCIS). You also do

not have to give us your immigration information if you are:

• Applying for emergency medical care only

• Helping someone else apply

• Not applying for yourself

Genetic Information

DHS does not collect, maintain or use genetic information

for purposes of eligibility.

Record Retention

Information provided in an application for coverage through

DHS is subject to the False Claims Act and may be kept for

up to 10 years. DHS follows the general records retention

schedules for state agencies and for the Department of

Human Services and maintains data according to state and

federal law. After the appropriate time period, DHS destroys

the data in a way that prevents their contents from being

determined, including by shredding paper files and

permanently removing electronic data so as to prevent

recovery.

Attachment - Keep this page.

Attachment B

Instructions for completing this application

Social Security number

Choose a reason for not applying for a Social Security number (SSN) and place your letter choice in the proper

question.

Reasons for not applying for an SSN:

A. Not eligible for an SSN

B. Can be issued for nonwork reason only

C. No SSN because of religious objections

D. No SSN as newborn or newly adopted

E. Other

Immigration status

Choose an immigration status from this list and place your letter choice in the proper question. The immigration

statuses with an asterisk (*) are qualified statuses.

A. American Indian born in Canada (Immigration and

Nationality Act [INA], section 289)*

B. Amerasian noncitizen*

C. Asylee*

D. Conditional entrant*

E. Cuban or Haitian entrant*

F. Deportation being withheld under section 243(h) or

231(b)(3) of the INA

G. Refugee*

H. Special Iraqi or Afghani immigrant*

I. Victim of severe trafficking (LPR or T Visa)*

J. Withholding of removal*

K. Battered noncitizen*

L. Lawful permanent resident (LPR)*

M. Paroled for at least one year*

N. Temporary nonimmigrant

O. Deferred action for childhood arrivals

Race (optional)

If you choose to answer the question about race, choose a race or races from this list and place your letter choice(s) in

the proper question.

A. White

B. Black or African American

C. American Indian or Alaska Native

D. Asian Indian

E. Chinese

F. Filipino

G. Japanese

H. Korean

I. Vietnamese

J. Other Asian

K. Native Hawaiian

L. Guamanian or Chamorro

M. Samoan

N. Other Pacific Islander

O. Other (please write in the race)

Attachment - Keep this page.

Attachment C

Agency Addresses

(Effective Date: October 2019)

Aitkin County

204 First Street NW

Aitkin, MN 56431-1291

218-927-7200 / 800-328-3744

Fax: 218-927-7210

Anoka County

Blaine Human Service Center

1201 89th Ave NE

Blaine, MN 55434

763-422-7200

Fax: 763-324-3620

Becker County

712 Minnesota Avenue

Detroit Lakes, MN 56501

218-847-5628

Fax: 218-847-6738

Beltrami County

616 America Ave NW

Bemidji, MN 56601

218-333-8300

Fax: 218-333-4150

Benton County

531 Dewey Street

Foley, MN 56329-0740

320-968-5087 / 800-530-6254

Fax: 320-968-5330

Big Stone County

340 2nd Street NW

P.O. Box 338

Ortonville, MN 56278-0338

320-839-2555

Fax: 320-839-3966

Blue Earth County

410 S 5th Street

Mankato, MN 56002-3526

507-304-4335

Fax: 507-304-4336

Brown County

1117 Center Street

New Ulm, MN 56073-0788

507-354-8246 / 800-450-8246

Fax: 507-359-6542

Carlton County

14 N. 11th Street, Suite 200

Cloquet, MN 55720-0660

218-879-4583 / 800-642-9082

Fax: 218-878-2500

Carver County

602 East Fourth Street

Chaska, MN 55318-2102

952-361-1600

Fax: 952-361-1660

Cass County

400 Michigan Avenue W

Walker, MN 56484-0519

218-547-1340

Fax: 218-547-1448

Chippewa County

719 N Seventh Street, Suite 200

Montevideo, MN 56265-1397

320-269-6401 / 877-450-6401

Fax: 320-269-6405

Chisago County

313 North Main Street, Rm 239

Center City, MN 55012-9665

651-213-5640 / 888-234-1246

Fax: 651-213-5685

Clay County

715 North 11th Street, Suite 502

Moorhead, MN 56560-2095

218-299-5200 / 800-757-3880

Fax: 218-299-7106

Clearwater County

216 Park Avenue NW

Bagley, MN 56621-9500

218-694-6164 / 800-245-6064

Fax: 218-694-3535

Cook County

411 West Second Street

Grand Marais, MN 55604-2307

218-387-3620

Fax: 218-387-3020

Cottonwood County

DVHHS

11 Fourth Street

Windom, MN 56101-0009

507-831-1891

Fax: 507-831-0126

Crow Wing County

204 Laurel Street

Brainerd, MN 56401-0686

218-824-1250 / 888-772-8212

Fax: 218-824-1305

Dakota County

1 Mendota Road West, #100

West St. Paul, MN 55118-4765

651-554-5611

Fax: 651-554-5748

Dodge County

MnPrairie

22 Sixth Street East, Dept. 401

Mantorville, MN 55955

507-923-2900 / 888-850-9419

Fax: 507-635-6186

Douglas County

809 Elm Street, Suite 1186

Alexandria, MN 56308

320-762-2302

Fax: 320-762-3833

Faribault County

FMCHS

412 Nicollet Street North

Blue Earth, MN 56013

507-526-3265

Fax: 507-526-2039

Fillmore County

902 Houston Street NW, #1

Preston, MN 55965-1080

507-765-2175

Fax: 507-765-3895

Freeborn County

203 W Clark Street

Albert Lea, MN 56007-1246

507-377-5400

Fax: 507-377-5498

Goodhue County

426 West Avenue

Red Wing, MN 55066

651-385-3200

Fax: 651-267-4879

Grant County

15 Central Avenue N, PO Box 1006

Elbow Lake, MN 56531-1006

218-685-8200 / 800-291-2827

Fax: 218-685-4978

Hennepin County

PO Box 107

Minneapolis, MN 55440-0107

612-596-1300

Fax: 612-288-2981

Call if you need office hours and

office location information.

Houston County

304 S. Marshall Street, Rm 104

Caledonia, MN 55921-0310

507-725-5811

Fax: 507-725-3990

Hubbard County

205 Court Avenue

Park Rapids, MN 56470

218-732-1451 / 877-450-1451

Fax: 218-732-3231

Isanti County

1700 E Rum River Dr S, Suite A

Cambridge, MN 55008-2547

763-689-1711

Fax: 763-689-9877

Itasca County

1209 SE Second Avenue

Grand Rapids, MN 55744-3983

218-327-2941 / 800-422-0312

Fax: 218-327-5548

Jackson County

DVHHS

407 5th Street, PO Box 67

Jackson, MN 56143-0067

507-847-4000

Fax: 507-847-5616

Kanabec County

905 Forest Avenue East, #150

Mora, MN 55051-1316

320-679-6350

Fax: 320-679-6351

Kandiyohi County

2200 23rd Street NE, Suite 1020

Willmar, MN 56201-9423

320-231-7800 / 877-464-7800

Fax: 320-231-6285

Kittson County

410 South Fifth Street, Suite 100

Hallock, MN 56728

218-843-2689 / 800-672-8026

Fax: 218-843-2607

Koochiching County

1000 Fifth Street

Int’l Falls, MN 56649-2485

218-283-7000 / 800-950-4630

Fax: 218-283-7013

Lac Qui Parle County

930 First Avenue

Madison, MN 56256-0007

320-598-7594

Fax: 320-598-7597

Lake County

616 Third Avenue

Two Harbors, MN 55616-1560

218-834-8400

Fax: 218-834-8412

Lake of the Woods County

206 8th Avenue SE, Suite 200

Baudette, MN 56623

218-634-2642

Fax: 218-634-4520

Le Sueur County

88 South Park Avenue

Le Center, MN 56057-1646

507-357-8288

Fax: 507-357-6122

Lincoln County

SWMHHS

319 N Rebecca Street

Ivanhoe, MN 56142

507-694-1452 / 800-657-3781

Fax: 507-694-1859

Lyon County

SWMHHS

607 West Main Street, Suite 100

Marshall, MN 56258

507-537-6747 / 800-657-3760

Fax: 507-537-6088

McLeod County

1805 Ford Avenue North, #100

Glencoe, MN 55336

320-864-3144 / 800-247-1756

Fax: 320-864-5265

Mahnomen County

311 N Main Street

Mahnomen, MN 56557-0460

218-935-2568

Fax: 218-935-5459

Attachment - Keep this page.

Marshall County

208 East Colvin Avenue, Suite 14

Warren, MN 56762-1695

218-745-5124 / 800-642-5444

Fax: 218-745-5260

Martin County

FMCHS

115 West First Street

Fairmont, MN 56031

507-238-4757

Fax: 507-238-1574

Meeker County

114 North Holcombe Ave, #180

Litchfield, MN 55355-2273

320-693-5300 / 877-915-5300

Fax: 320-693-5344

Mille Lacs County

525 Second Street SE

Milaca, MN 56353

320-983-8208 / 888-270-8208

Fax: 320-983-8306

MinnesotaCare Operations

540 Cedar Street

PO Box 64252

St. Paul, MN 55164-0252

651-297-3862 / 800-657-3672

Fax: 651-431-7750

Morrison County

213 SE First Avenue

Little Falls, MN 56345-3196

320-632-2951 / 800-269-1464

Fax: 320-632-0225

Mower County

201 1st Street NE, Suite 18

Austin, MN 55912-3405

507-437-9700

Fax: 507-437-9721

Murray County

SWMHHS

3001 Maple Road, Suite 100

Slayton, MN 56172

507-836-6144 / 800-657-3811

Fax: 507-836-8841

Nicollet County

622 South Front Street

St. Peter, MN 56082-2106

507-934-8559

Fax: 507-934-8552

Nobles County

318 9th Street

PO Box 189

Worthington, MN 56187-0189

507-295-5213

Fax: 507-372-5094

Norman County

15 Second Avenue East, Room 108

Ada, MN 56510-1389

218-784-5400

Fax: 218-784-7142

Olmsted County

2117 Campus Drive SE, Suite 200

Rochester, MN 55904

507-328-6500

Fax: 507-328-7956

Otter Tail County

535 Fir Avenue W

Fergus Falls, MN 56537

218-998-8230

Fax: 218-998-8270

Pennington County

318 N Knight Avenue

Thief River Falls, MN 56701-0340

218-681-2880

Fax: 218-683-7013

Pine County

315 Main Street S, Suite 200

Pine City, MN 55063

320-591-1570

Fax: 320-591-1601

1610 Highway 23 N

Sandstone, MN 55072-5009

Fax: 320-591-1601

Pipestone County

SWMHHS

1091 North Hiawatha Avenue

Pipestone, MN 56164

507-825-6720 / 888-632-4325

Fax: 507-825-5649

Polk County

612 N Broadway, Room 302

Crookston, MN 56716

218-281-3127 / 877-281-3127

Fax: 218-281-3926

1424 Central Avenue NE

East Grand Forks, MN 56721

218-773-2431

Fax: 218-773-3602

250 SW Cleveland Avenue

PO Box 100

McIntosh, MN 56556

21-435-1585 / 877-281-3127

Fax: 218-435-1552

Pope County

211 East MN Avenue, Suite 200

Glenwood, MN 56334-1629

320-634-7755

Fax: 320-634-0164

Ramsey County

160 East Kellogg Boulevard

St. Paul, MN 55101-1494

651-266-4444

Fax: 651-266-3942

Red Lake County

125 Edward Avenue SW

Red Lake Falls, MN 56750-0356

218-253-4131 / 877-294-0846

Fax: 218-253-2926

Redwood County

SWMHHS

266 E Bridge Street

Redwood Falls, MN 56283

507-637-4050 / 888-234-1292

Fax: 507-637-4055

Renville County

105 S 5th Street, Suite 203H

Olivia, MN 56277

320-523-2202

Fax: 320-523-3565

Rice County

320 NW Third Street, #2

Faribault, MN 55021-0718

507-332-6115

Fax: 507-332-6247

Rock County

SWMHHS

2 Roundwind Road

Luverne, MN 56156-0715

507-283-5070

Fax: 507-283-5074

Roseau County

208 6th Street SW

Roseau, MN 56751-1451

218-463-2411 / 866-255-2932

Fax: 218-463-3872

St. Louis County

320 West 2nd Street

Duluth, MN 55802-1495

218-726-2101 / 800-450-9777

Fax: 218-726-2163

307 S 1st Street – PO Box 1148

Virginia, MN 55792-1148

218-471-7137

Fax: 218-471-7123

320 Miners Drive E

Ely, MN 55731-1402

218-365-8220

Fax: 218-365-8217

1814 14th Avenue East

Hibbing, MN 55746-1314

218-262-6000

Fax: 218-262-6049

Scott County

752 Canterbury Rd S

Shakopee, MN 55379

952-496-8686

Fax: 952-496-8685

Sherburne County

13880 Business Center Drive

Elk River, MN 55330-4600

763-765-4000 / 800-433-5239

Fax: 763-765-4096

Sibley County

PO Box 237

Gaylord, MN 55334-0237

507-237-4000

Fax: 507-237-4031

Stearns County

705 Courthouse Square

St. Cloud, MN 56302-1107

320-656-6000 / 800-450-3663

Fax: 320-656-6447

Steele County

MnPrairie

630 Florence Avenue

Owatonna, MN 55060-0890

507-431-5600

Fax: 507-635-6186

Stevens County

400 Colorado Avenue, Suite 104

Morris, MN 56267-1235

320-208-6600 / 800-950-4429

Fax: 320-589-3972

Swift County

410 21st Street South

Benson, MN 56215-0208

320-843-3160

Fax: 320-843-4582

Todd County

212 Second Avenue South

Long Prairie, MN 56347-1640

320-732-4500 / 888-838-4066

Fax: 320-732-4540

Traverse County

202 8th Street North

Wheaton, MN 56296

320-422-7777 / 855-735-8916

Fax: 320-563-4230

Wabasha County

411 Hiawatha Drive E

Wabasha, MN 55981-1573

651-565-3351 / 888-315-8815

Fax: 651-565-3084

Wadena County

124 First Street SE

Wadena, MN 56482-1553

218-631-7605 / 888-662-2737

Fax: 218-631-7616

Waseca County

MnPrairie

299 Johnson Avenue SW, Suite 160

Waseca, MN 56093-2498

507-837-6600

Fax: 507-635-6186

Washington County

14949 62nd Street North

PO Box 30

Stillwater, MN 55082-0030

651-430-6455

Fax: 651-430-6605

Watonwan County

715 Second Avenue S

St. James, MN 56081-1741

507-375-3294 / 888-299-5941

Fax: 507-375-7359

Wilkin County

227 6th Street North

PO Box 369

Breckenridge, MN 56520-0369

218-643-7161

Fax: 218-643-7175

Winona County

202 West Third Street

Winona, MN 55987-3146

507-457-6200

Fax: 507-454-9381

Wright County

1004 Commercial Drive

Buffalo, MN 55313-1736

763-682-7414 / 800-362-3667

Fax: 763-682-7701

Yellow Medicine County

415 9th Avenue, Suite 202

Granite Falls, MN 56241

320-564-2211

Fax: 320-564-4165

White Earth Financial Services

PO Box 100

Nay-tah-waush, MN 56566

218-935-5554

Appendix A – American Indian or Alaska Native Family Member (AI or AN)

American Indians and Alaska Natives (AI and AN) have certain health coverage benefits and protections. If you or your

family members qualify, some income and assets might not count toward your eligibility, and you may not be

required to pay co-pays, deductibles, or monthly premiums for some programs. Complete this appendix and submit it

with your application if you want to apply for these exceptions.

You must provide proof of AI or AN status. Proof can be a document issued by an AI or AN tribe, such as an

enrollment or membership card; a document from the Indian Health Service (IHS) showing the person may get IHS

services as an American Indian; or a document from the Bureau of Indian Affairs (BIA) that says the person is an

American Indian.

Note: If you have more people to include, make copies of this page and attach them.

1. Name (First Name, Middle Name, Last Name)

2. Is this person receiving or has this person ever

received a service from the Indian Health Service,

a tribal health program or an urban Indian health

program or through a referral from one of these

programs?

3. Certain money received may not be counted for

Medical Assistance (MA). Some assets also may

not be counted for MA or are excluded as an asset

for up to one year after receipt. List any income

and assets (amount and how often received)

reported on your application that include money

from these sources:

• For income:

• Per capita payments from a tribe that come

from natural resources, usage rights, rent,

leases or royalties

• Cobell Settlement payments for American

Indians or Alaska Claims Settlement Act

payments

• Payments from natural resources, farming,

ranching, fishing, leases, or royalties from land

designated as Indian trust land by the

Department of Interior (Including reservations

and former reservations)

• Money from selling things that have cultural

significance

• For assets:

• Money that you still have from any of the

income sources listed previously

• Real property located on Indian land or land

held in a trust

• Ownership interests in rents, leases, royalties,

or usage rights related to natural resources or

things that have cultural significance.

4. Does this person live on a reservation?

AI or AN PERSON 1

First

Middle

Last

Yes No

Income $

Type

How often?

Assets $

Type

Yes No

AI or AN PERSON 2

First

Middle

Last

Yes No

Income $

Type

How often?

Assets $

Type

Yes No

Appendix B – Authorized Representative Designation

You can choose an authorized representative.

You can give a trusted person permission to talk about this application with us, see your information and act for you

on matters related to this application, including getting information about your application and signing your

application on your behalf. This person is called an "authorized representative." If you ever need to change your

authorized representative, contact your county or tribal agency. Contact information is listed in Attachment C.

A legally appointed representative for someone on this application must submit proof with the application.

1. NAME OF AUTHORIZED REPRESENTATIVE (First Name, Middle Name, Last Name) RELATIONSHIP TO YOU, IF ANY

2. ADDRESS 3. APARTMENT OR SUITE NUMBER

4. CITY 5. STATE 6. ZIP CODE

7. PHONE NUMBER 8. ORGANIZATION NAME 9. ID NUMBER (if applicable)

By signing, you allow this person to sign your application, get official information about this application and act for

you on all future matters with this agency.

10. YOUR SIGNATURE 11. DATE (MM/DD/YYYY)

Authorized Representative Signature

By signing, I agree to be an authorized representative for this household. I understand my responsibilities including

keeping information about the people applying on this application private.

I would like to get information by email at:

AUTHORIZED REPRESENTATIVE SIGNATURE DATE (MM/DD/YYYY)

Civil Rights Notice

CB3 (HC-Medical) 3-18

Discrimination is against the law. The Minnesota Department of Human Services (DHS) does not discriminate on the basis

of any of the following:

• race

• color

• national origin

• creed

• religion

• sexual orientation

• public assistance status

• marital status

• age

• disability

• sex

(including sex stereotypes and gender identity)

• political beliefs

Auxiliary Aids and Services: DHS provides

auxiliary aids and services, like qualified

interpreters or information in accessible formats,

free of charge and in a timely manner to ensure

an equal opportunity to participate in our health

care programs. Call 651-431-2670 or

800-657-3739 or use your preferred relay service.

Language Assistance Services: DHS provides translated

documents and spoken language interpreting, free of

charge and in a timely manner, when language

assistance services are necessary to ensure limited

English speakers have meaningful access to our

information and services. Call 651-431-2670 or

800-657-3739 or use your preferred relay service.

Civil Rights Complaints

You have the right to file a discrimination complaint if

you believe you were treated in a discriminatory way by a

human services agency. You may contact any of the

following three agencies directly to file a discrimination

complaint.

U.S. Department of Health and Human Services' Office

for Civil Rights (OCR)

You have the right to file a complaint with the OCR, a

federal agency, if you believe you have been

discriminated against because of any of the following:

• race

• color

• national origin

• age

• disability

• sex

Contact the OCR directly to file a complaint:

Director, U.S. Department of Health and Human

Services' Office for Civil Rights

200 Independence Avenue SW, Room 509F

HHH Building

Washington, DC 20201

800-368-1019 (voice) • 800-537-7697 (TDD)

Complaint Portal:

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Minnesota Department of Human Rights (MDHR)

In Minnesota, you have the right to file a complaint with

the MDHR if you believe you have been discriminated

against because of any of the following:

• race

• color

• national origin

• religion

• creed

• sex

• sexual orientation

• marital status

• public

assistance

status

• disability

Contact the MDHR directly to file a complaint:

Minnesota Department of Human Rights

Freeman Building, 625 North Robert Street

St. Paul, MN 55155

651-539-1100 (voice) • 800-657-3704 (toll free)

711 or 800-627-3529 (MN Relay) • 651-296-9042 (fax)

[email protected] (email)

DHS

You have the right to file a complaint with DHS if you

believe you have been discriminated against in our

health care programs because of any of the following:

• race

• color

• national origin

• creed

• religion

• sexual orientation

• public assistance status

• marital status

• age

• disability

• sex

(including sex

stereotypes and gender

identity)

• political beliefs

Complaints must be in writing and filed within 180 days

of the date you discovered the alleged discrimination.

The complaint must contain your name and address and

describe the discrimination you are complaining about.

After we get your complaint, we will review it and notify

you in writing about whether we have authority to

investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s

outcome. You have the right to appeal the outcome if

you disagree with the decision. To appeal, you must send

a written request to have DHS review the investigation

outcome. Be brief and state why you disagree with the

decision. Include additional information you think is

important.

If you file a complaint in this way, the people who work

for the agency named in the complaint cannot retaliate

against you. This means they cannot punish you in any

way for filing a complaint. Filing a complaint in this way

does not stop you from seeking out other legal or

administrative actions.

Contact DHS directly to file a discrimination complaint:

Civil Rights Coordinator

Minnesota Department of Human Services

Equal Opportunity and Access Division

P.O. Box 64997

St. Paul, MN 55164-0997

651-431-3040 (voice) or use your preferred relay service

651-431-2670 or 800-657-3739

For accessible formats of this information or

assistance with additional equal access to

human services, write to [email protected],

call 800-657-3739, or use your preferred relay

service. ADA1 (2-18)