Renewal Forms (Archive)

The following forms are used during the renewal process:

l  Minnesota Health Care Programs Renewal (DHS-3418).

This is the renewal form sent to enrolled clients to gather eligibility information. It must be completed and returned to continue eligibility.

n The client provides data similar to what is requested on an application including but not limited to the following information:

m List of household members.

m Income.

m Assets.

m Health insurance.

m Other changes.

n  It also includes a medical release, along with the client’s rights and responsibilities.

n  It may also be used to apply for household members not currently covered.

n  Do not require a DHS-3418 if the following forms are received instead:

m Combined Application Form (CAF) (DHS-5223).

m Long-Term Care and Elderly Waiver Renewal (DHS-2128).

l  Combined Application Form (CAF) (DHS-5223) for people receiving cash assistance or Food Support (FS). A person who is also receiving health care with these programs will be sent the CAF if the renewal date corresponds with the recertification date for FS and cash.

l  Long-Term Care and Elderly Waiver Renewal (DHS-2128).

This is the form used to renew eligibility, both annually and at six months, for people residing in long-term care (LTC) facilities or receiving waiver services (CAC, CADI, DD, TBI, EW). This includes LTC residents who receive MSA for personal needs and EW enrollees residing in GRH facilities and receiving GRH payments.

l  Request for Signature (DHS-3555).

This signature form is sent with the renewal form. It explains:

n  Who should sign the renewal.

n  What will happen if the renewal is returned without a signature.

See Renewal Signatures for information on who must sign the renewal.

l  Health Care Coverage Options in Minnesota brochure (DHS-3416).

This brochure explains different public and private health care options available to residents of Minnesota.

l  MA-BC Application/Renewal (DHS-3525) and Certification of Further Treatment Required (DHS-3525A).

These two forms are used exclusively for MA Breast and Cervical Cancer enrollees to renew coverage. Do not require these forms if another renewal form is received.

l  Household Report Form (HRF) (DHS-2120).

This form is used when a client is required to renew eligibility monthly. See Monthly Renewal for more information on monthly reporters.

l  Notice of Late or Incomplete Household Report Form or Health Care Renewal Form (DHS-2414).

This is a notice sent to clients when their benefits are being terminated because they failed to return the required report form or the form was not completed correctly. The back of the form lists the client appeal rights information.

l  Combined Six-Month Report (DHS-5576).

This form is sent to MA/GAMC clients for their six-month renewal and MA clients for their income and asset six-month renewal.

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