Get Rule 25 Eligibility Application - Olmsted County Minnesota - Co Olmsted Mn

This guide provides step-by-step instructions on how to complete the Rule 25 Eligibility Application online in Olmsted County, Minnesota. By following these instructions, users can ensure their application is filled out accurately and comprehensively.

Follow the steps to complete your application efficiently.

1. Press the ‘Get Form’ button to access the Rule 25 Eligibility Application and open it in the editor.
2. Begin by filling in your name and date of birth in the respective fields as accurately as possible.
3. Provide your Social Security Number (SSN) in the designated field.
4. Indicate whether you are a resident of Olmsted County by selecting 'Yes' or 'No.'
5. Enter your complete address, including any apartment number if applicable.
6. Fill in your phone numbers, including a primary phone and a secondary cell number.
7. Select your gender and indicate your race by checking the appropriate boxes.
8. For marital status, select the option that applies to you: Single, Married, Separated, Widowed, or Divorced.
9. Answer whether you have had a previous Chemical Health Assessment/Rule 25 by selecting 'Yes' or 'No'. If yes, provide the date and place.
10. Select who referred you for a Rule 25 assessment from the provided options, or indicate 'Other' and specify.
11. Indicate if you are currently in treatment by selecting 'Yes' or 'No.'
12. Answer if you have Medical Assistance (MA) or Minnesota Care and provide your MA number if applicable.
13. Provide details about any private insurance or HMO coverage, and submit a copy of your insurance card (front and back).
14. Fill out the household size section by noting who you live with, excluding unmarried partners or their children.
15. Provide your income details, including two recent proofs of income. Specify amounts and frequencies for each source of income listed.
16. Indicate your preferred method of receiving notice regarding your eligibility for a chemical health assessment and provide the necessary contact information.
17. Sign and date the form to authorize the submission of your application.
18. After completing all required sections, save your changes, and download, print, or share the form as needed.

Complete your application online today for timely processing!