Dhs 3418 eng-2025

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The document DHS-3418-ENG is a renewal form for Minnesota Health Care Programs. It outlines the steps individuals must take to complete their renewal, including reading privacy notices, answering questions about their living situation and income, providing necessary proofs, and submitting the form to the appropriate agency. The document emphasizes the importance of timely submission to avoid coverage interruption and provides contact information for assistance. Additionally, it includes details on privacy practices, rights and responsibilities regarding personal information, and instructions for reporting changes in circumstances.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information in Section 1, including your name, address, date of birth, and Social Security number. Ensure all details are accurate.
In Section 2, list others living with you. Provide their names, relationships, and indicate if they are applying for coverage now.
For Sections 3 and 4, report any self-employment or employment details. Include monthly income and expenses as required.
Complete Sections 5 through 20 by detailing any additional income sources, assets, or changes in health insurance. Attach necessary proofs as indicated.
Finally, review the Signature Page carefully. Sign and date the form before submitting it via mail or fax to your county agency.

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