DHS-5274-ENG (Child Care Assistance Program

Clear Form
*DHS-5274-ENG*
DHS-5274-ENG
2-15
Minnesota Child Care Assistance Program
Redetermination Form
This is the Minnesota Child Care Assistance Program (CCAP) Redetermination Form. You must complete this form if you
want to continue to get help with your child care expenses so you can work, look for work, or attend school.
To qualify, your family must:
„„ Be income eligible;
„„ Meet employment and training requirements:
• Comply with the activities of an approved Minnesota Family Investment Program (MFIP)/ Diversionary Work Program
(DWP) employment plan, or
• Participate in job search, attend school or training classes, or
• Work at least an average of 20 hours per week (10 hours per week if a full-time student) at minimum wage.
„„ Cooperate with child support enforcement for all children in the family who have an absent parent; and
„„ Use a legal child care provider. (Legal providers include licensed and unlicensed providers, 18 years of age or older, who are
registered with the county to provide care.)
Please follow these instructions as you complete your Redetermination Form.
„„ Print your answers using black ink.
„„ Read all instructions carefully and answer all questions completely. Include your case number on the form. If you do
not know your case number contact your worker.
„„ Attach additional sheets of paper if you need more space.
„„ Include proof of all requested information.
„„ Carefully read the “Penalty warning”, “Your responsibilities” and “Your rights” sections and the “Notice of Privacy
Practices” pages of this form (this information is on tear-off pages for you to keep). Sign and date the Redetermination
Form on page 7.
„„ Mail, fax or bring the completed form and all other needed items to your child care worker.
„„ If you do not complete this form and provide proofs by the due date shown on the cover letter, your child care
assistance will end.
If you have questions about completing this Redetermination Form or have problems getting the information you need,
please call your child care worker.
Your child care worker will write or call you if more information is needed. Once all information is received your worker
will send you a written notice about your eligibility.
APPLICANT NAME
PHONE NUMBER
CASE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
(Send proof of current address, such as a copy of a utility bill or other mail with your name listed.)
Page 1 of 12
1. Tell us who is living in your home
Include all household members, both adults and children. Include family members who do not currently live with you, but
are expected to return to live in your home.
RACE CODES: (Choose all that apply)
A = Asian
B = Black or African American N= American Indian/Alaska Native
P = Pacific Islander/Native Hawaiian
W = White
Person 1
NAME
RELATIONSHIP
ETHNICITY (optional)
Hispanic/Latino
Person 2
GENDER
DATE OF BIRTH
Self
RACE (optional, see Race codes above)
Yes
NAME
RELATIONSHIP TO PERSON 1
ETHNICITY (optional)
Hispanic/Latino
SOCIAL SECURITY NUMBER
No
GENDER
DATE OF BIRTH
RACE (optional)
Yes
SOCIAL SECURITY NUMBER
No
Absent parent (Complete this section if Person 2 is a child)
DOES CHILD HAVE A PARENT WHO IS NOT LIVING IN THE HOME?
Yes
SHARED CUSTODY
No
Yes
NAME OF ABSENT PARENT
SHARED CUSTODY SCHEDULE
Person 3
RELATIONSHIP TO PERSON 1
NAME
ETHNICITY (optional)
Hispanic/Latino
No
GENDER
Yes
No
DATE OF BIRTH
RACE (optional)
Yes
RECEIVE CHILD SUPPORT
SOCIAL SECURITY NUMBER
No
Absent parent (Complete this section if Person 3 is a child)
DOES CHILD HAVE A PARENT WHO IS NOT LIVING IN THE HOME?
Yes
SHARED CUSTODY
No
Yes
NAME OF ABSENT PARENT
SHARED CUSTODY SCHEDULE
Person 4
RELATIONSHIP TO PERSON 1
NAME
ETHNICITY (optional)
Hispanic/Latino
No
GENDER
Yes
No
DATE OF BIRTH
RACE (optional)
Yes
RECEIVE CHILD SUPPORT
SOCIAL SECURITY NUMBER
No
Absent parent (Complete this section if Person 4 is a child)
DOES CHILD HAVE A PARENT WHO IS NOT LIVING IN THE HOME?
Yes
SHARED CUSTODY
No
Yes
NAME OF ABSENT PARENT
SHARED CUSTODY SCHEDULE
Person 5
RELATIONSHIP TO PERSON 1
NAME
ETHNICITY (optional)
Hispanic/Latino
No
GENDER
Yes
No
DATE OF BIRTH
RACE (optional)
Yes
RECEIVE CHILD SUPPORT
SOCIAL SECURITY NUMBER
No
Absent parent (Complete this section if Person 5 is a child)
DOES CHILD HAVE A PARENT WHO IS NOT LIVING IN THE HOME?
Yes
No
NAME OF ABSENT PARENT
Page 2 of 12
SHARED CUSTODY
Yes
No
RECEIVE CHILD SUPPORT
Yes
No
SHARED CUSTODY SCHEDULE
DHS-5274-ENG 2-15
2. Tell us about your income and the income of all family members who
live with you:
Earned Income
Is anyone employed?
No
Yes – complete for each person working:
NAME
EMPLOYER NAME
EMPLOYER ADDRESS
HOURLY WAGE
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
HOURS PER WEEK
$
HOW OFTEN ARE YOU PAID
Weekly
Every two weeks
Twice a month
Monthly
Times/Days worked during the week
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
NAME
FRIDAY
SATURDAY
EMPLOYER NAME
EMPLOYER ADDRESS
HOURLY WAGE
SUNDAY
FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN)
HOURS PER WEEK
$
HOW OFTEN ARE YOU PAID
Weekly
Every two weeks
Twice a month
Monthly
Times/Days worked during the week
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
(Send proof of work schedules and all earned income for the past 30 days.)
Self-employment
Is anyone self-employed?
No
Yes – complete for each person working. Attach additional sheet of paper if more space is needed.
NAME
TYPE OF BUSINESS
START DATE
HOURS PER WEEK
MONTHLY INCOME
MONTHLY EXPENSES
$
$
(Send a copy of the most recent federal income tax forms and all related schedules for anyone who is self-employed.)
Unearned Income
Does anyone in the household get any of the following types of income?
No
Yes – complete for each person who has income from any of the sources listed below
• Public assistance (DWP, MFIP,
• RSDI (Retirement, survivors, disability insurance)
• Interest/dividends
GA, Tribal TANF)
• Relative custody assistance
• Student grants or scholarships
• VA (Veteran benefits)
• Insurance benefits
• Post-secondary child care grant award
• Worker’s compensation
• Child support
• Student loans
• Unemployment insurance
• Spousal support
• Stipends
• SSI (Supplemental Security
• Other child care assistance
• Other (lottery or gambling winnings, inheritance,
Income)
• Tribal payments
insurance disbursements, etc.)
Name
Source
Amount
$
$
$
$
How often received?
Weekly
Monthly
Weekly
Monthly
Weekly
Monthly
Weekly
Monthly
Twice a month
Every two weeks
Twice a month
Every two weeks
Twice a month
Every two weeks
Twice a month
Every two weeks
(Send proof of unearned income for the past 30 days.)
Page 3 of 12
DHS-5274-ENG 2-15
Expected changes income
IF YOU EXPECT CHANGES, PLEASE EXPLAIN
3. Tell us if you pay or anyone in your family pays for the following
expenses:
„„ Medical insurance
„„ Vision insurance
„„ Dental insurance
„„ Spousal support
„„ Child
support for a child
not living in your home
„„ Education
expenses (Tuition, fees,
books* and living expenses**)
(Send proof of expenses, such as check stubs, benefit statements, premium statements or award letters.)
NAME
EXPENSE
AMOUNT
HOW OFTEN DO YOU PAY?
Weekly
$
Every two weeks
NAME
Twice a month
Monthly
EXPENSE
AMOUNT
HOW OFTEN DO YOU PAY?
Weekly
$
Every two weeks
NAME
Twice a month
Monthly
EXPENSE
AMOUNT
HOW OFTEN DO YOU PAY?
Weekly
$
Every two weeks
Twice a month
Monthly
* Only include these expenses if student receives scholarships, grants, student loans or work-study income.
**Only include living expenses if student receives student loan income.
4. Parent student information
(If you need child care for your education, send proof of transcripts and school schedules that show the days and times
classes meet, including school breaks.)
PARENT NAME
GRADE
START DATE
SCHOOL NAME
EXPECTED DATE OF COMPLETION
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
PARENT NAME
FRIDAY
GRADE
SATURDAY
SUNDAY
START DATE
SCHOOL NAME
EXPECTED DATE OF COMPLETION
Times/Days student attends school
MONDAY
Page 4 of 12
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
DHS-5274-ENG 2-15
5. Child student information:
Complete this section for all children in your family who are now in school or plan to go to school within the next six
months. If the child is in preschool, indicate “Head Start” or “preschool” in the grade field. If child is in kindergarten,
indicate half day or full day in the grade field. Include proof of school schedules for every child who needs child care, such as
a school calendar with start and end times.
STUDENT’S NAME
GRADE
START DATE (if not currently attending)
SCHOOL NAME
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
STUDENT’S NAME
FRIDAY
SATURDAY
SUNDAY
GRADE
START DATE (if not currently attending)
SCHOOL NAME
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
STUDENT’S NAME
FRIDAY
SATURDAY
SUNDAY
GRADE
START DATE (if not currently attending)
SCHOOL NAME
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
STUDENT’S NAME
FRIDAY
SATURDAY
SUNDAY
GRADE
START DATE (if not currently attending)
SCHOOL NAME
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
STUDENT’S NAME
FRIDAY
SATURDAY
SUNDAY
GRADE
START DATE (if not currently attending)
SCHOOL NAME
Times/Days student attends school
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Comments
Page 5 of 12
DHS-5274-ENG 2-15
6. Child care needs
CHILD’S NAME
PROVIDER’S NAME
PROVIDER’S ADDRESS
CITY
STATE
ZIP CODE
Hours/Days child care needed
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
CHILD’S NAME
FRIDAY
SATURDAY
SUNDAY
PROVIDER’S NAME
PROVIDER’S ADDRESS
CITY
STATE
ZIP CODE
Hours/Days child care needed
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
CHILD’S NAME
FRIDAY
SATURDAY
SUNDAY
PROVIDER’S NAME
PROVIDER’S ADDRESS
CITY
STATE
ZIP CODE
Hours/Days child care needed
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
CHILD’S NAME
FRIDAY
SATURDAY
SUNDAY
PROVIDER’S NAME
PROVIDER’S ADDRESS
CITY
STATE
ZIP CODE
Hours/Days child care needed
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
CHILD’S NAME
FRIDAY
SATURDAY
SUNDAY
PROVIDER’S NAME
PROVIDER’S ADDRESS
CITY
STATE
ZIP CODE
Hours/Days child care needed
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
7. Family services
a. Do you receive a housing or Section 8 subsidy?
b. Do you receive Supplemental Nutrition Assistance Program (SNAP) benefits?
Yes
No
Yes
No
c. Do any children in your household attend Head Start?
Yes
No
If yes, name(s)
,
,
Comments
Page 6 of 12
DHS-5274-ENG 2-15
Authorization to share information for fraud investigation and audits
I agree that third parties may share information about me with persons investigating fraud and conducting Federal or state
audits. This may include, but is not limited to:
„„ Employers and schools,
„„ Financial and insurance agencies, and
„„ Landlords and utility companies,
„„ Other government offices.
I understand this consent is good for six months after my benefits stop.
Provider release
State and federal privacy laws protect my information. If I am eligible for child care assistance, CCAP staff can share
information about the hours and amount of child care assistance I get with my child care provider(s). I understand:
„„ This information must be shared so that my child care
„„ I may cancel this authorization with written notice
provider knows how much CCAP will pay for the child
anytime. This written notice will not affect information
care provided.
already released.
„„ This information can be shared only if I give my written
„„ The person or agency who gets my information may be
permission or if the law allows it.
able to pass it onto others.
„„ I can refuse to sign or cancel this release, but if I do,
„„ If my information is passed onto others by DHS, it may
CCAP may not be able to pay my provider for the child
no longer be protected by this authorization.
care provided.
This authorization will end one year from the date I sign it. Minnesota Data Privacy Act [Minnesota Statutes, chapter 13].
Penalty warning
If you get child care assistance benefits, you must follow these rules.
„„ Do not give false information or hide information:
„„ To help someone else to get or to continue to get child
care assistance payments.
„„ To get or continue to get child care assistance benefits
The state may bar a family with a member who breaks either of these rules from the Child Care Assistance Program. The
bar lasts three months for the first fraud, six months for the second fraud, two years for the third fraud and is permanent for
the fourth fraud. Effective February 1, 2014: The bar lasts one year for the first fraud, two years for the second fraud and is
permanent for the third fraud. The maximum penalty is a fine of $100,000 or a jail term of 20 years, or both.
Perjury and general declarations
I declare under the penalties of perjury that this application has been examined by me and to the best of my knowledge
is a true and correct statement of every material point. I understand that a person convicted of perjury may be sentenced
to imprisonment of not more than five years or payment of a fine of not more than $10,000, or both. [Minnesota Statute,
section 256.984, subd. 1]
By signing below:
„„ I have received a copy of the Notice of Privacy Practices
(DHS-3979) and the Client Responsibilities and
Rights (DHS‑4163). I have read, and understand this
information. If I have questions about this information,
I will ask a worker to explain them to me.
„„ I agree to continue to assign my child care support to
the state of Minnesota. I understand that I have the
right to claim good cause for not cooperating with child
support enforcement.
„„ I agree to the sharing of information as stated in the
provider release and fraud investigation authorization
information above.
APPLICANT/HEAD OF HOUSEHOLD SIGNATURE
HOME PHONE NUMBER
WORK PHONE NUMBER
DATE
OTHER ADULT FAMILY MEMBER SIGNATURE
DATE
Attachments: Change Report Form (DHS-4794)
Page 7 of 12
DHS-5274-ENG 2-15
Attention. If you need free help interpreting this document, ask your worker or call the number below for
your language.
.1-800-358-0377 ‫ اطلب ذلك من مشرفك أو اتصل على الرقم‬،‫ إذا أردت مساعدة مجانية لترجمة هذه الوثيقة‬:‫مالحظة‬
kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmsYrG~kkan’sMNuMerOg rbs’G~k ÉehATUrs&BÍmklex
1-888-468-3787 .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, pitajte vašeg radnika ili nazovite
1-888-234-3785.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces nug koj tus neeg lis dej num los sis hu rau 1-888-486-8377.
້ ຣີ, ຈງ່ ົ ຖາມພະນ ັກງານກາກ
ໂປຣດຊາບ. ຖາ້ ຫາກ ທາ່ ນຕອ
� ັບການຊວ
້ ງການການຊວ
່ ຍເຫຼືອໃນການແປເອກະສານນີຟ
່ ຍເຫຼືອ
ຂອງທາ່ ນ ຫຼື ໂທຣໄປທີ່ 1-888-487-8251.
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, hojjettoota kee gaafadhu ykn afaan
ati dubbattuuf bilbilli 1-888-234-3798.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, обратитесь к
своему социальному работнику или позвоните по телефону 1-888-562-5877.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, hawlwadeenkaaga
weydiiso ama wac lambarka 1-888-547-8829.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi nhân viên xã hội của quý vị hoặc gọi
số 1-888-554-8759.
LB1-0001 (3-13)
Atención. Si desea recibir asistencia gratuita para interpretar este documento, comuníquese con su trabajador
o llame al 1-888-428-3438.
ADA5 (12-12)
This information is available in accessible formats for individuals
with disabilities by contacting your county worker. For other
information on disability rights and protections to access human
services programs, contact the agency’s ADA coordinator.
Page 8 of 12
DHS-5274-ENG 2-15
Client Responsibilities and Rights
DHS-4163-ENG 9-14
NOTE: Cash on an EBT card is provided to help families meet their basic needs. These basic needs include food, shelter, clothing,
utilities and transportation. These funds are given until families can support themselves. It is illegal for an EBT user to buy or attempt to buy
tobacco products or alcohol with the EBT card. If you do, it is fraud and you will be removed from the program. Do not use an EBT card at a
gambling establishment.
Your responsibilities
„„ You must report changes which may affect your benefits
to the county agency within 10 days after the change has
occurred. Applicants - Report these changes to your worker
when the change happens.
This includes the following for everyone in your household:
• Employment - Start or stop a job or business; change in
hours, earnings or expenses.
• Income - Receipt or change in child support, Social Security,
Veteran benefits, Unemployment Insurance, inheritance,
insurance benefits and other payments.
• Property - Purchase, sale or transfer of a house, car or other
items of value. Get an inheritance or a settlement
• Household - When a person dies or becomes disabled, moves
in or out of your home or temporarily leaves; pregnancy;
birth of a child.
• Address
• Housing costs/rent subsidy
• Utility costs
• Filing a lawsuit
• Absent parent custody or visits
• Drug felony conviction
• Marriage, separation or divorce
• School attendance
• Health insurance coverage and premiums.
Note about child care providers: If you change providers, you
must tell your child care worker and provider at least 15 days
before the change goes into effect.
If you have any questions or are unsure about any reporting
rules, contact your worker. If your worker is not available, leave
a message so the worker can get back to you.
„„ The county, state or federal agency may check any of the
information you give. To get some information we must have
your signed consent. If you don’t allow the county to confirm
your information, you might not get assistance.
„„ If you give us information you know is untrue or we get
information you did not report, we will investigate you
for fraud.
„„ The State or Federal Quality Control agency may randomly
choose your case for review. They will review statements you
made on forms. They will check to see if we figured your
eligibility correctly. The state agency may seek information from
other sources. The State or Federal Quality Control agency will
tell you about any contact they intend to make. If you do not
cooperate, your benefits may stop.
„„ Cooperation requirements:
• If the county approves you for the Minnesota Family
Investment Program (MFIP) or the Diversionary Work
Program (DWP), you must cooperate with employment
services, unless you are exempt. You must develop and sign an
employment plan or your DWP application will be denied.
Page 9 of 12
• To receive Family Cash Benefits and/or Child Care
Assistance (CCAP), you must cooperate with child support
enforcement for all children in your household. You have the
right to claim “good cause” for not cooperating with child
support enforcement. You must assign your child support to
the State of Minnesota for all eligible children. If you do not
cooperate or assign your child support, benefits will be denied
or terminated.
• After the county approves your MFIP or DWP, if you get
child support directly from the noncustodial parent, you
must report it to your worker. You must cooperate with the
child support agency in any legal action brought against
a third party for payment of medical expenses, unless you
claim and are granted good cause.
• If you are applying for health care for yourself and your
children and you do not live with the other parent, you may
have to give information about the other parent to child
support staff. Child support staff may use this information
to pursue medical support for your children. You do not have
to give this information if you are only applying for your
children or are pregnant.
• Household members applying for health care may need to
accept and keep other health insurance that is available. This
includes Medicare. If you do not give us information about
your policy, you may not get coverage.
For Cash and SNAP:
„„ Each time you use your electronic benefits transfer (EBT)
card or sign your check, you state that you have informed the
county agency about any changes in your situation which may
affect your benefits.
Each time your electronic benefits transfer (EBT) card is
used we assume you have received your cash or SNAP benefits,
unless you reported your card lost or stolen to the county agency.
For Child Care:
„„ You may be required to pay a co-payment fee. If you do not
pay the fee, your Child Care Assistance will be terminated until
fees are paid in full or satisfactory payment agreements have
been made with the county and your child care provider. Your
Child Care Assistance worker will tell you whether to pay this
fee to your child care provider or to the county agency.
„„ You may be required to pay additional costs when your child
care provider charges a rate that is more than the maximum rate
in your county.
„„ You must document the immigration or citizenship status of
the children in your family for whom you are applying for child
care assistance.
NOTE: If you sign this application as an Authorized
Representative of a person who is requesting or receiving
assistance, you are agreeing to assume all of the responsibilities
listed above on behalf of that person.
DHS-5274-ENG 2-15
Your rights
„„ Your right to privacy. Your private information, including
your health information, is protected by state and federal laws.
Your worker has given you a Notice of Privacy Practices (DHS3979) information sheet explaining these rights.
„„ You have the right to reapply at any time if your benefits stop.
„„ You have the right to know why, if we have not processed
your application promptly.
• 15 days for medical care for pregnant women
• 30 days for cash, SNAP and child care
• 45 days for medical care
• 60 days for cash and medical care related to disability.
„„ You have the right to know the rules of the program you
are applying for and for us to tell you how we figured your
benefits.
„„ You have the right to choose where and with whom you
live and, within certain limits, to choose your own doctor,
hospital, etc.
„„ Appeal rights. If you are unhappy with the action taken or
feel the agency did not act on your request for assistance, you
may appeal. For cash, child care and health care, you may
appeal within 30 days from the date you receive the notice
by writing to the county agency, or directly to the State
Appeals Office at the Minnesota Department of Human
Services, PO Box 64941, St. Paul, MN 55164-0941. (If you
show good cause for not appealing your cash and health
care within 30 days, the agency can accept your appeal for
up to 90 days from the date you receive the notice.) For
SNAP, you may appeal within 90 days by writing or calling
the county or the State Appeals Office. You may represent
yourself at the hearing, or you may have someone (an
attorney, relative, friend or another person) speak for you.
If you wish your assistance to continue until the hearing,
you must appeal before the date of the proposed action or
within 10 days after the date the agency notice was mailed,
whichever is later. Ask your county worker to explain how
the timing of your appeal could affect your present or future
assistance.
„„ Access to free legal services. Contact your worker for
information on free legal services.
Discrimination is against the law.
You have the right to file a complaint if you believe you were treated
in a discriminatory way by a human services agency. You can contact
any of the following agencies directly to file a civil rights complaint.
The Minnesota Department of Human Services, Equal
Opportunity and Access Division, prohibits discrimination in
its programs because of race, color, national origin, creed, religion,
sexual orientation, public assistance status, age, disability or sex.
Contact the Equal Opportunity and Access Division directly:
Minnesota Department of Human Services
Equal Opportunity and Access Division
P.O. Box 64997
St. Paul, MN 55164-0997
651‑431‑3040 (voice) or use your preferred relay service
The Minnesota Department of Human Rights prohibits
discrimination in public services programs because of race, color,
creed, religion, national origin, disability, sex, sexual orientation,
or public assistance status. Contact the Minnesota Department of
Human Rights directly:
Minnesota Department of Human Rights
Freeman Building, 625 North Robert Street
St. Paul, MN 55155
651‑539‑1100 (voice) 800‑657‑3704 (toll free)
651‑296‑1283 (TTY)
The U.S. Department of Health and Human Services’ Office
for Civil Rights prohibits discrimination in its programs because of
race, color, national origin, age, disability and in some cases religion
and sex. Contact the federal agency directly:
U.S. Department of Health and Human Services
Office for Civil Rights, Region V
233 North Michigan Avenue, Suite 240
Chicago, IL 60601
312‑886‑2359 (voice) 800‑368‑1019 (toll free)
800‑537‑7697 (TTY)
Page 10 of 12
The U.S. Department of Agriculture prohibits discrimination
against its customers, employees, and applicants for employment
on the bases of race, color, national origin, age, disability,
sex, gender identity, religion, reprisal, and where applicable,
political beliefs, marital status, familial or parental status,
sexual orientation, or all or part of an individual’s income is
derived from any public assistance program, or protected genetic
information in employment or in any program or activity
conducted or funded by the Department. (Not all prohibited
bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of
discrimination, complete the USDA Program Discrimination
Complaint Form, found online at www.ascr.usda.gov/complaint_
filing_cust.html, or at any USDA office, or call 866‑632‑9992
to request the form. You may also write a letter containing all
of the information requested in the form. Send your completed
complaint form or letter to us by mail at U.S. Department
of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, by
fax 202‑690‑7442 or email at [email protected]
Individuals who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal Relay Service
at 800‑877‑8339; or 800‑845‑6136 (Spanish).
For any other information dealing with Supplemental Nutrition
Assistance Program (SNAP) issues, persons should either contact
the USDA SNAP Hotline Number at 800‑221‑5689, which is
also in Spanish or call the State Information/Hotline Numbers
(click the link for a listing of hotline numbers by State); found
online at www.fns.usda.gov/snap/contact_info/hotlines.htm.
USDA is an equal opportunity provider and employer.
DHS-5274-ENG 2-15
DHS-3979-ENG
8-11
Minnesota Department of Human Services
Notice of Privacy Practices
(Effective Date: August 2011)
This notice tells how medical and other private information about you may be used and disclosed and how you can
get this information. Please review it carefully.
Why do we ask for this information?
„„ To tell you apart from other people with the same or
similar name
„„ To decide what you are eligible for
„„ To help you get medical, mental health, financial
or social services and decide if you can pay for
some services
„„ To make reports, do research, do audits, and evaluate
our programs
„„ To investigate reports of people who may lie about the
help they need
„„ To decide about out-of-home care and in-home care for
you or your children
„„ To collect money from other agencies, like insurance
companies, if they should pay for your care
„„ To decide if you or your family need protective services
„„ To collect money from the state or federal government
for help we give you.
Why do we ask you for your Social
Security number?
We need your Social Security number (SSN) to give you
medical assistance, some kinds of financial help, or child
support enforcement services (42 CFR 435.910 [2006];
Minn. Stat. 256D.03, subd.3(h); Minn. Stat.256L.04,
subd. 1a; 45 CFR 205.52 [2001]; 42 USC 666; 45 CFR
303.30 [2001]). We also need your SSN to verify identity
and prevent duplication of state and federal benefits.
Additionally, your SSN is used to conduct computer data
matches with collaborative, nonprofit and private agencies
to verify income, resources, or other information that may
affect your eligibility and/or benefits.
You do not have to give us the SSN:
„„ For persons in your home who are not applying
for coverage
„„ If you have religious objections
„„ If you are not a U.S. citizen and are applying for
Emergency Medical Assistance only
„„ If you are from another country, in the U.S. on a
temporary basis and do not have permission from the
U.S. Citizenship and Immigration Services (USCIS) to
live in the U.S. permanently
„„ If you are living in the U.S. without the knowledge or
approval of the USCIS.
Page 11 of 12
Do you have to answer the questions
we ask?
You do not have to give us your personal information.
Without the information, we may not be able to help you.
If you give us wrong information on purpose, you can be
investigated and charged with fraud.
With whom may we share information?
We will only share information about you as needed and as
allowed or required by law. We may share your information
with the following agencies or persons who need the
information to do their jobs:
„„ Employees or volunteers with other state, county, local,
federal, collaborative, nonprofit and private agencies
„„ Researchers, auditors, investigators, and others who
do quality of care reviews and studies or commence
prosecutions or legal actions related to managing the
human services programs.
„„ Court officials, county attorney, attorney general, other
law enforcement officials, child support officials, and
child protection and fraud investigators
„„ Human services offices, including child support
enforcement offices
„„ Governmental agencies in other states administering
public benefits programs
„„ Health care providers, including mental health agencies
and drug and alcohol treatment facilities
„„ Health care insurers, health care agencies, managed care
organizations and others who pay for your care
„„ Guardians, conservators or persons with power
of attorney
„„ Coroners and medical investigators if you die and they
investigate your death
„„ Credit bureaus, creditors or collection agencies if you do
not pay fees you owe to us for services
„„ Anyone else to whom the law says we must or can give
the information.
We may disclose your health information to a record
locator service. This can help health care providers find
health plans and other health care providers that have
health information about you. The health care provider
can then get that information to help make better decisions
about your treatment. If you prefer not to be included in
the record locator service, you may “opt out” by contacting
DHS-5274-ENG 2-15
the Community Health Information Collaborative (CHIC)
service desk at 877‑411‑CHIC (toll free), 218-625-5515
(voice), 218-625-5518 (fax).
What are your rights regarding the
information we have about you?
„„ You and people you have given permission to may see
and copy medical or other private information we have
about you. You may have to pay for the copies.
„„ You may question if the information we have about you
is correct. Send your concerns in writing. Tell us why the
information is wrong or not complete. Send your own
explanation of the information you do not agree with.
We will attach your explanation any time information is
shared with another agency.
„„ You have the right to ask us in writing to share health
information with you in a certain way or in a certain
place. For example, you may ask us to send health
information to your work address instead of your home
address. If we find that your request is reasonable, we
will grant it.
„„ You have the right to ask us to limit or restrict the way
that we use or disclose your information, but we are not
required to agree to this request.
„„ You have the right to get a record of some of the people
or organizations with whom we have shared your
information. This record was started on April 14, 2003.
You must ask for a copy of this record in writing to our
Privacy Official.
„„ If you do not understand the information, ask your
worker to explain it to you. You can ask the Minnesota
Department of Human Services for another copy of
this notice.
What are our responsibilities?
„„ We must protect the privacy of your medical and other
private information according to the terms of this notice.
„„ We may not use your information for reasons other than
the reasons listed on this form or share your information
with individuals and agencies other than those listed on
this form unless you tell us in writing that we can.
„„ We must follow the terms of this notice, but we may
change our privacy policy because privacy laws change.
We will put changes to our privacy rules on our website
at: http://edocs.dhs.state.mn.us/lfserver/Public/
DHS‑3979‑ENG
Page 12 of 12
What privacy rights do children have?
If you are under 18, when parental consent for medical
treatment is not required, information will not be shown
to parents unless the health care provider believes not
sharing the information would risk your health. Parents
may see other information about you and let others see this
information, unless you have asked that this information
not be shared with your parents. You must ask for this in
writing and say what information you do not want to share
and why. If the agency agrees that sharing the information
is not in your best interest, the information will not be
shared with your parents. If the agency does not agree, the
information may be shared with your parents if they ask
for it.
What if you believe your privacy rights have
been violated?
You may complain if you believe your privacy rights have
been violated. You cannot be denied service or treated badly
because you have made a complaint. If you believe that
your medical privacy was violated by your doctor or clinic,
a health insurer, a health plan, or a pharmacy, you may
send a written complaint either to the county agency, the
organization or to the federal civil rights office at:
U.S. Department of Health and Human Services
Office for Civil Rights, Region V
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
312-886-2359 (Voice) or
toll free 800-368-1019 or 866-282-0659
312-353-5693 (TTY)
312-886-1807 (Fax)
If you think that the Minnesota Department of Human
Services has violated your privacy rights, you may send a
written complaint to the U.S. Department of Health and
Human Services at the address above or to:
Minnesota Department of Human Services
Attn: Privacy Official
P.O. Box 64998
St. Paul, MN 55164-0998
DHS-5274-ENG 2-15