MN DHS-3437-ENG 2011-2025 free printable template
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Clear Form×DHS3437ENG*
DHS3437ENGCase number:Minnesota Health Care ProgramsGiving Permission for
Someone to Act on My Behalf Case name:
Worker name:
Worker phone number:Date:Fax number:To:Agency
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How to fill out MN DHS-3437-ENG
How to fill out MN DHS-3437-ENG
01
Start with the header section and fill in your name and other personal information.
02
Indicate the purpose of the form by checking the appropriate box.
03
Provide details regarding your living situation, including your address and household members.
04
Fill in income information, listing all sources of income and the amounts.
05
Include information about any assets you own, such as bank accounts or property.
06
Review the completed form for accuracy and completeness.
07
Sign and date the form before submission.
Who needs MN DHS-3437-ENG?
01
Individuals or families seeking assistance or benefits from the Minnesota Department of Human Services.
02
Applicants for aid programs like Supplemental Nutrition Assistance Program (SNAP) or Medical Assistance.
03
Anyone required to report changes in income or household size while receiving benefits.
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People Also Ask about
What is the income limit for MinnesotaCare?
MinnesotaCare is for families with income at or below 200% of the Federal Poverty Guidelines (FPG) ($27,180 per year for an individual; $55,500 for a family of four), but above 138% of FPG ($18,754 for an individual; $38,295 for a family of four). MinnesotaCare counts most types of earned and unearned income you have.
Does a health care directive need to be notarized in MN?
Part III: Making The Document Legal This document must be signed by me. It also must be verified either by a notary public (Option 1) OR witnessed by two witnesses (Option 2). It must be dated when it is verified or witnessed .
What is the income limit for MN care?
MinnesotaCare is for families with income at or below 200% of the Federal Poverty Guidelines (FPG) ($27,180 per year for an individual; $55,500 for a family of four), but above 138% of FPG ($18,754 for an individual; $38,295 for a family of four). MinnesotaCare counts most types of earned and unearned income you have.
Which form do you use to apply for Minnesota health care programs?
How do I apply? Apply online through MNsure, Minnesota's health insurance marketplace. Here are some tips for completing the MNsure online application. Fill out and return the MNsure paper application DHS-6696 (PDF).
Is MinnesotaCare the same as Medicaid?
Medical Assistance (MA) is Minnesota's Medicaid program for people with low income. MA does not require you to pay a monthly premium. MA members have small co-pays for some services, usually $1 - $3. MinnesotaCare is a program for Minnesotans with low incomes who do not have access to affordable health care coverage.
How do I fill out a Minnesota healthcare directive?
How Do I Make a Health Care Directive? Be in writing and dated. State your name. Be signed by you or someone you authorize to sign for you, when you can understand and communicate your health care wishes. Have your signature verified by a notary public or two witnesses.
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What is MN DHS-3437-ENG?
MN DHS-3437-ENG is a form used by the Minnesota Department of Human Services to collect specific information for reporting purposes regarding eligibility and services.
Who is required to file MN DHS-3437-ENG?
Individuals or organizations applying for or receiving certain services from the Minnesota Department of Human Services are required to file MN DHS-3437-ENG.
How to fill out MN DHS-3437-ENG?
To fill out MN DHS-3437-ENG, you should carefully read the instructions provided with the form, provide accurate personal and financial information, and submit it by the specified deadline.
What is the purpose of MN DHS-3437-ENG?
The purpose of MN DHS-3437-ENG is to ensure that the Minnesota Department of Human Services has the necessary information to assess eligibility for services and to monitor compliance with state requirements.
What information must be reported on MN DHS-3437-ENG?
Information that must be reported on MN DHS-3437-ENG includes personal identification details, income information, and any other relevant data that impacts eligibility for the services requested.
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