Dhs 6696-2026

The document DHS-6696-ENG 11-21 is an application form for health coverage and financial assistance in Minnesota. It provides information on how to apply for health insurance, eligibility criteria, required documentation, and the types of coverage available, including Medical Assistance and MinnesotaCare. The application can be completed online for faster processing, and it includes sections for family members, income details, and consent for sharing medical information. Additionally, it outlines privacy practices and rights related to health coverage.

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Click ‘Get Form’ to open the DHS 6696 application in our platform.
Begin by filling out the 'People to include on this application' section. List all family members living with you, including yourself, spouse, and children under 19.
Proceed to Step 2 for each person listed. Enter their first name, last name, date of birth, and sex. Ensure to provide a Social Security number if available.
Complete the income information for each family member. This includes employer details and expected wages. Use our editor's features to easily input and adjust figures.
Review your entries for accuracy before submitting. Utilize the 'Preview' feature in our platform to ensure all information is correct.
Once completed, follow the instructions in Step 8 to submit your application via fax, mail, or in person.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (110 Votes)
2016	4.4 Satisfied (34 Votes)

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