Get MN DHS-3418-ENG 2020-2024

DHS-3418-ENG Minnesota Health Care Programs Renewal What do I need to do with this form 1. Read the Notice of Privacy Practices and Rights and Responsibilities on pages A through C at the back of this form. Tear them off and keep them. 2. We may not use your information for reasons other than the reasons listed on this form or share your information with individuals and agencies other than those listed on this form unless you tell us in writing that we can. We must follow the terms of this notice but we may change our privacy policy because privacy laws change. We will put changes to our privacy rules on our website at http //edocs. dhs. state. mn.us/lfserver/Public/DHS-3979-ENG If you think that the Minnesota Department of Human Services has violated your privacy rights you may send a written complaint to the U.S. Department of Health and Human Services at the address above or to Attn Privacy Official PO Box 64998 St. Paul MN 55164-0998 Rights and Responsibilities Immigration information you give to us is private. Answer all questions. If you need more space write the question number and the answer on a separate piece of paper. Include it with the form* 3. Sign and date form* 4. Attach proofs. A list of the proofs needed is below. 5. Return form and proofs to see if coverage can continue. Send these proofs for anyone who is Working Pay stubs from the last 30 days or a written statement of earnings from your employer if you do not have pay stubs. Self-employed Most recent income tax returns including all schedules. If you have not filed taxes send copies of your income and expense records for the last year. Getting other income A statement from the person or company that sends the income copy of checks award letter court order or other documents from the last 30 days. Bank accounts Current bank statements or statement from bank showing current balance or value of accounts. Other assets Copies of bonds stock ownership statements or other documents showing value of assets. Send copies of proofs. Do not send original documents. If we do not get these proofs your health care coverage may stop* Your worker may ask for additional proofs. If you need help getting proofs call your worker. What will happen if I do not return this form Coverage will stop if you do not return this form by the due date. Questions If you have questions or need help filling out this form call your worker right away. 7-13 Attention* If you need free help interpreting this document ask your worker or call the number below for your language. 1-800-358-0377 kMNt sMKal. ebIG k tUvkarCMnYyk gkarbkE b ksarenHeday tKit f sUmsYrG kkan sMNuMerOg rbs G k ehATUrs B mklex 1-888-468-3787. Pa nja* Ako vam treba besplatna pomo za tuma enje ovog dokumenta pitajte va eg radnika ili nazovite 1-888-234-3785. Thov ua twb zoo nyeem* Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb ces nug koj tus neeg lis dej num los sis hu rau 1-888-486-8377.