Get Mn Dhs-4796-eng 2010-2025

The MN DHS-4796-ENG is an essential form for reporting changes in your circumstances to the Minnesota Health Care Programs. This guide provides clear instructions to help you complete the form effectively and submit it online.

Follow the steps to accurately complete your change report form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date of the change at the top of the form. This is crucial as it indicates when the change occurred.
3. Provide your case number in the specified field, ensuring you keep this number handy for future references.
4. Fill in the name of the worker assigned to your case, along with their phone number, as it may be needed for follow-up.
5. Input your own name and case name in the corresponding fields.
6. Indicate your new address or phone number if applicable, ensuring accuracy for effective communication.
7. If you are adding or changing the person acting on your behalf, check the 'YES' box to indicate this, and you will receive the necessary form to fill out.
8. Provide information on your employment status. Indicate if you started, stopped, or changed jobs. Include your employer's name, phone number, and address.
9. Report your monthly gross income, which is the amount you expect to make each month from your job.
10. If self-employed, indicate if your business has started or stopped, and provide the business name and expected monthly net income.
11. List any other income changes, including but not limited to child support or day care payments, and specify the amounts.
12. Document any medical expenses that are not covered by your health care insurance, detailing each expense carefully.
13. If there are changes to your assets, please indicate the owner’s name, the type of asset, and its value.
14. For household member changes, specify if anyone has moved in or out, and provide their details.
15. Finally, check the box indicating if you are applying for assistance, sign the form, and add the date.
16. After completing the form, ensure to save your changes. You may also download, print, or share the form as needed.

Complete your MN DHS-4796-ENG form online today to ensure your information is up-to-date.