Dhs 2128 eng-2026

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The document DHS-2128-ENG outlines the renewal process for individuals receiving long-term care services under the Minnesota Health Care Programs (MHCP). It provides detailed instructions on completing the renewal form, including necessary proofs and deadlines. The document emphasizes the importance of timely submission to avoid coverage interruption and includes information on privacy practices, rights and responsibilities, and potential consequences for failing to report changes in circumstances. Additionally, it addresses various financial disclosures required for eligibility assessment.

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Click ‘Get Form’ to open it in the editor.
Begin by reading the Notice of Privacy Practices and Notice of Rights and Responsibilities on Attachment A. Tear off these pages for your records.
Fill in your personal information in Section 1, including your name, address, date of birth, and phone number. Ensure accuracy as this information is crucial for processing.
Indicate whether you are currently in a long-term care facility and provide the necessary details if applicable.
Complete questions regarding your financial situation, including cash on hand, bank accounts, assets, and income sources. Use additional sheets if needed.
Sign and date the form at the designated section. You can do this electronically within our platform for convenience.
Attach any required proofs as copies (not originals) and submit the completed form to your county or tribal agency promptly.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (130 Votes)
2015	4.3 Satisfied (263 Votes)

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