MN DHS DHS-5204-ENG 2009 free printable template

Clear Form Data FILLABLE FORM DHS-5204-ENG Rule 25 Assessment Alcohol and Drug Abuse Division Instructions This form has been designed with fillable form fields and the capability to save completed forms on your computer. The assessment may resume when the conditions in item a b or c are resolved. l This interview was not completed. Reason Actions taken PMI or insurance number DHS Rule 25 Assessment 1 of 18 8-09 Background Information 1. CURRENT ADDRESS CITY 15. CLIENT PHONE NUMBER 16....

How to fill out MN DHS DHS-5204-ENG

How to fill out MN DHS DHS-5204-ENG

1. Begin by downloading the MN DHS DHS-5204-ENG form from the Minnesota Department of Human Services website.
2. Fill out the personal information section at the top, including your name, address, and contact details.
3. Provide information regarding your household members, including their names, relationships, and ages.
4. Indicate your income sources and amounts, making sure to be as accurate as possible to avoid discrepancies.
5. Review the eligibility criteria listed on the form to ensure you meet all necessary requirements.
6. Complete any additional sections that apply to your situation, such as expenses or special circumstances.
7. Sign and date the form at the end, confirming the information provided is truthful and accurate.
8. Submit the completed form to the designated address or agency as instructed in the guidelines.

Who needs MN DHS DHS-5204-ENG?

1. Individuals seeking financial assistance or social services in Minnesota may need to fill out the MN DHS DHS-5204-ENG form.
2. Families and caretakers who are applying for health care programs or benefits related to children or dependent adults.
3. Persons needing to determine eligibility for various support programs offered by the Minnesota Department of Human Services.

People Also Ask about

How do I schedule a Rule 25 in MN?

Call 612.249. 3656 to schedule your Rule 25 assessment in Minneapolis or the surrounding metro.

What is the rule 25 assessment in Hennepin County?

What is a Rule 25 in Hennepin County? A Rule 25 is a chemical health evaluation conducted by a licensed medical professional. The evaluation itself requires a face-to-face interview between the medical professional and the person in need of a chemical dependency evaluation.

What is the rule 25 assessor in Minnesota?

A Rule 25 assessment using the Rule 25 Assessment Tool and Minnesota Matrix is required for any person seeking public payment for SUD treatment services, whether the person is assessed by his or her county or tribal nation of residence.

How much does a Rule 25 cost in Minnesota?

This is an individual choice. If you do not want to use insurance, do not have insurance, or your plan will not cover the cost, you have the option to pay out of pocket for that assessment. The fee is $250 and it covers all portions of the assessment.

How long is a Rule 25 good for MN?

Patients who are ready for chemical health treatment must get a Rule 25 Assessment (for patients with MA) or a chemical dependency assessment (for patients with private insurance). The Rule 25/CD Assessment is conducted by a CD Assessor who creates an Assessment Summary and Plan that is good for 45 days.

What is the Schedule A Rule 25 in Minnesota?

Schedule a Rule 25 Assessment today The Rule 25 evaluation determines if you have an alcohol or drug related diagnosis, makes appropriate recommendations and referrals for individuals with substance use disorders (also called drug addiction, chemical dependency or alcoholism).

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What is MN DHS DHS-5204-ENG?

MN DHS DHS-5204-ENG is a form used by the Minnesota Department of Human Services for reporting certain information related to health care or social service programs.

Who is required to file MN DHS DHS-5204-ENG?

Individuals or entities participating in Minnesota's health care or social services programs that require reporting specific data are required to file MN DHS DHS-5204-ENG.

How to fill out MN DHS DHS-5204-ENG?

To fill out MN DHS DHS-5204-ENG, users must carefully follow the instructions provided with the form, ensuring all required fields are completed accurately and submitting any necessary documentation that supports the information reported.

What is the purpose of MN DHS DHS-5204-ENG?

The purpose of MN DHS DHS-5204-ENG is to collect and verify information necessary for the administration and monitoring of health care and social services provided in the state of Minnesota.

What information must be reported on MN DHS DHS-5204-ENG?

The information that must be reported on MN DHS DHS-5204-ENG typically includes personal identification details, program participation information, income details, and other relevant data required by the Minnesota Department of Human Services.