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DHS-3163B-ENG (Referral to Support and Collections) This form is used by MinnesotaCare, Medical Assi 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in your personal information in Section 1. Include your last name, first name, middle name, and other relevant details such as your address and social security number.
- In Section 2, provide information about the other parent or alleged father. If applicable, indicate if they are deceased and include their details.
- Section 3 requires you to list children living with you. Fill in each child's name, gender, date of birth, and their relationship to the other parent using the provided codes.
- Complete Sections 4 and 5 with employment information for both you and the other parent, including employer details and any child support payment history.
- In Section 6, indicate whether there is a court order for medical support from the other parent. Provide necessary insurance details if applicable.
- Finally, review all sections for accuracy before signing at the end of the form. Ensure that all required fields are completed.
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