Get Enrollment Form - Minnesota Department Of Human Services - Dhs State Mn

Filling out the Enrollment Form for the Minnesota Department of Human Services is an essential step in securing health care coverage under the Special Needs Basic Care program. This guide provides a clear, step-by-step approach to completing the form online.

Follow the steps to successfully complete the enrollment form.

1. Click the ‘Get Form’ button to access the enrollment form. This will allow you to open the form in the appropriate editor.
2. Begin by entering your last name and first name in the designated fields. This information is essential for identifying your application.
3. Fill in your county of residence and then note your MI (Minnesota Identification) number if applicable. Include your birthdate and home phone number in the specified sections.
4. Provide your social security number, although this field is optional. It may assist in identifying your records.
5. Indicate your gender by checking the appropriate box.
6. Complete your street address, city, state, and ZIP code. If your mailing address differs from your residential address, fill out those fields as well.
7. Include your Medical Assistance ID number, which can be found on your Minnesota Health Care Program card. Also, providing an email address is optional.
8. If you require an interpreter, check the appropriate option and select the language needed from the provided list.
9. Indicate whether you are pregnant by checking 'yes' or 'no'.
10. If you have other medical coverage, check 'yes' and provide the required insurance details, including the insurance company name, policyholder’s name, and policy number.
11. Decide whether you would like to enroll in the Special Needs Basic Care program. If you choose not to, check the corresponding box.
12. If you intend to enroll, select one health plan from the list provided. Ensure that only one option is selected, as failing to do so may automatically assign you to a plan.
13. Indicate your chosen Primary Care Clinic and enter the clinic number.
14. Read the agreements and conditions on the back of the form carefully. By signing, you agree to the terms outlined regarding your health care coverage and responsibilities.
15. Sign and date the form at the designated section. If you are completing the form on behalf of another individual, include your relationship to the enrollee.
16. Return the completed form using the provided envelope, or you may mail it to the Minnesota Department of Human Services or fax it to the indicated number, ensuring that your submission is secure.

Complete your Enrollment Form online today to ensure you receive the healthcare coverage you need.