MINNESOTA GOVERNMENT DATA PRACTICES ACT INVENTORY OF NOT PUBLIC DATA ON INDIVIDUALS Yellow Medicine County Responsible Authority – Rae Ann Keeler-Aus Family Service Center, Director Department/Division Human Services – Income Maintenance Name of Form, Record, File, System, or Process Description (Purpose, what it collects, in terms understandable by general public) Classification Designee DHS - 0033 Appeal to State Agency Private Robin Schoep, Income Maintenance Supervisor DHS – 0035 State Agency Appeals Summary Private Robin Schoep, Income Maintenance Supervisor DHS – 1609 Nonreceipt/Replacement Affidavit Private Robin Schoep, Income Maintenance Supervisor DHS – 1795 SSI Interim Assistance Authorization Private Robin Schoep, Income Maintenance Supervisor DHS – 1795A Interim Assistance Agreement Private Schoep, Income Maintenance Supervisor DHS – 1844 Medical Expenses Request Private Robin Schoep, Income Maintenance Supervisor DHS – 1922B MHCP Health Insurance Information Form (HIIF) Private Robin Schoep, Income Maintenance Supervisor DHS – 2116 Notice to Apply for Other Maintenance Benefits Private Schoep, Income Maintenance Supervisor DHS – 2120 Household Report Form Private Robin Schoep, Income Maintenance Supervisor DHS – 2128 LTC Renewal Private Schoep, Income Maintenance Supervisor DHS – 2136 SNAP Claim Determination Report Private Robin Schoep, Income Maintenance Supervisor DHS – 2146 Auth. for Release of Employment Info Private Schoep, Income Maintenance Supervisor DHS – 2237A Medical Service Questionnaire Private Robin Schoep,
Income Maintenance Supervisor DHS – 2243 Authorization for Release of Information About Assets Private Robin Schoep, Income Maintenance Supervisor DHS – 2243A General Consent for Release of Information Private Robin Schoep, Income Maintenance Supervisor DHS – 2338 Client Statement of Good Cause Private Robin Schoep, Income Maintenance Supervisor DHS – 2402 Change Report Form Private Robin Schoep, Income Maintenance Supervisor DHS – 2414 Notice of late or Incomplete HCRF or CSR Private Schoep, Income Maintenance Supervisor DHS – 2646 Financial Aid Information Form Private Robin Schoep, Income Maintenance Supervisor DHS – 2686A Child Support Enforcement Notification Private Robin Schoep, Income Maintenance Supervisor DHS – 2775 Notice of Overpayment Private Schoep, Income Maintenance Supervisor DHS – 2776 MFIP Overpayment Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – SNAP Overpayment Worksheet Private Schoep, Income Maintenance Supervisor DHS – 2776B Computation of Work Benefit Overpayment Worksheet Private Schoep, Income Maintenance Supervisor DHS – Computation of DWP Overpayment Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – 2808 Gift or Loan Statement Private Robin Schoep, Income Maintenance Supervisor DHS – 2841 Cost Effective Insurance Information Private Robin Schoep, Income Maintenance Supervisor
DHS – 2841A Cost Effective Insurance Calculation Private Robin Schoep, Income Maintenance Supervisor DHS – 2841B Cost Effective Insurance Referral – Applicant Private Robin Schoep, Income Maintenance Supervisor DHS – 2841C Cost Effective Insurance Determination Private Robin Schoep, Income Maintenance Supervisor DHS – 2841D Cost Effective Insurance Prorating Premium & Deductible Amounts Private Robin Schoep, Income Maintenance Supervisor DHS – 2882 Referral of Minor Parent to Social Services Private Robin Schoep, Income Maintenance Supervisor DHS – 2883 Request for Verification of School Attendance/Progress Private Robin Schoep, Income Maintenance Supervisor DHS – 2917 Reporting Child Abuse and Neglect Private Schoep, Income Maintenance Supervisor DHS – Verification Request Form A Private Robin Schoep, Income Maintenance Supervisor DHS – 2919B Verification Request Form B Private Robin Schoep, Income Maintenance Supervisor DHS – 2952 Auth. for Release of Info About Residence and Shelter Expenses Private Robin Schoep, Income Maintenance Supervisor DHS – 2975 Transition Year Medical Assistance Quarterly Report Private Robin Schoep, Income Maintenance Supervisor DHS – Transition Year Medical Assistance First Quarterly Report Private Robin Schoep, Income Maintenance Supervisor DHS – 2982 County Parental Fee Referral to DHS Private Schoep, Income Maintenance Supervisor DHS – 2984 Request for Voluntary Vendor Payment Private Schoep, Income Maintenance Supervisor DHS – 2992 Authorization to Share Information Private Robin Schoep,
DHS – 3165A SNAP E&T Status Update Form Private Robin Schoep, Income Maintenance Supervisor DHS – 3165R RCA Status Update Form Private Schoep, Income Maintenance Supervisor DHS – 3166 Employment Services Referral Private Robin Schoep, Income Maintenance Supervisor DHS – 3175 MFIP Notice of Intent to Sanction Private Robin Schoep, Income Maintenance Supervisor DHS – 3180 Client Option Spenddown Bill Private Schoep, Income Maintenance Supervisor DHS – 3195 Incoming Inter Agency Case Transfer Form Private Robin Schoep, Income Maintenance Supervisor DHS – 3203 MA Lien & Notice of Potential Claim Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – 3227 Failure to Comply Notice SNAP E&T Private Robin Schoep, Income Maintenance Supervisor DHS – 3247 Family Guide to Child Protection Private Robin Schoep, Income Maintenance Supervisor DHS – 3261 Expense Reimbursement Form Private Robin Schoep, Income Maintenance Supervisor DHS – 3271 MHCP Request for Information Private Schoep, Income Maintenance Supervisor DHS – 3308A Minnesota Health Care Programs Memo Private Robin Schoep, Income Maintenance Supervisor DHS – 3323 Family Violence Referral Private Robin Schoep, Income Maintenance Supervisor DHS – 3328 MHCP - Request for Social Security Number Private Schoep, Income Maintenance Supervisor DHS – 3335A Fraud Prevention Investigation Referral Private Robin Schoep,
Income Maintenance Supervisor DHS – 3336 Self-employment Report Form Private Robin Schoep, Income Maintenance Supervisor DHS – 3340 Asset Assessment for MA for LTC Services Private Robin Schoep, Income Maintenance Supervisor DHS – 3340A MHCP Asset Evaluation Results for MA-LTC Private Schoep, Income Maintenance Supervisor DHS – 3340C MHCP Designation of Assets Private Robin Schoep, Income Maintenance Supervisor DHS – 3341 Asset Reduction Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – 3348 Employer Insurance Information Form Private Schoep, Income Maintenance Supervisor DHS – 3354C PMAP Questionnaire Private Robin Schoep, Income Maintenance Supervisor DHS – 3360 Electronic Funds Transfer Private Robin Schoep, Income Maintenance Supervisor DHS – 3365 Mandatory Vendor Form Private Robin Schoep, Income Maintenance Supervisor DHS – 3385 & 3386 Authorization for Release of Info Fraud Investigation FPI Permission to Search Private Robin Schoep, Income Maintenance Supervisor DHS – 3418 MN HCAPP Renewal Private Schoep, Income Maintenance Supervisor DHS – 3429 Disqualification Consent Agreement Private Schoep, Income Maintenance Supervisor DHS – 3437 Permission for Someone to Act on Your Behalf Private Robin Schoep, Income Maintenance Supervisor DHS – 3439 Medicare Buy-in Referral Letter Private Robin Schoep, Income Maintenance Supervisor
DHS – 3443 Individual Discharge Info Sheet (Prison) Private Robin Schoep, Income Maintenance Supervisor DHS – 3444 MHCP Medicare Application Referral Letter Private Robin Schoep, Income Maintenance Supervisor DHS – 3453 MHCP Sponsor Letter Private Robin Schoep, Income Maintenance Supervisor DHS – 3478 Title IV-E Foster Care Supplement to HC Program Application Private Robin Schoep, Income Maintenance Supervisor DHS – 3531 MHCP Application for Payment of LTC Services Private Robin Schoep, Income Maintenance Supervisor DHS – 3543 Request for Payment of LTC Services Private Robin Schoep, Income Maintenance Supervisor DHS – 3547 MA –EPD Initial Premium Notice Private Schoep, Income Maintenance Supervisor DHS – 3549 General Consent/Auth for Release of Information Private Schoep, Income Maintenance Supervisor DHS – 3550 CCAP Application Private Schoep, Income Maintenance Supervisor DHS – 3552 Direct Deposit for MCCAP Private Robin Schoep, Income Maintenance Supervisor DHS – 3627 Important Info About Your Request for a CS Good Cause Exemption Private Robin Schoep, Income Maintenance Supervisor DHS – 3628 Notice of Denial of CS Good Cause Exemption Private Robin Schoep, Income Maintenance Supervisor DHS – 3629 Notice of CS Good Cause Approval Private Robin Schoep, Income Maintenance Supervisor DHS – 3630 Notice of Child Support Good Cause Redetermination Private Robin Schoep, Income Maintenance Supervisor DHS – 3631 Request to End Child Support Good Cause Exemption Private Robin Schoep,
Income Maintenance Supervisor DHS – 3632 Req. for Additional Info to Prove Your CS Good Cause Exemption Private Robin Schoep, Income Maintenance Supervisor DHS – 3633 Notice of Approval of Redetermination of Your CS Good Cause Exemption Private Robin Schoep, Income Maintenance Supervisor DHS – 3727 Combined Annual Renewal for Certain Populations Private Robin Schoep, Income Maintenance Supervisor DHS – 3985 Privacy Practices for CCAP Providers Private Robin Schoep, Income Maintenance Supervisor DHS – 4003 Care Status Transmittal Private Robin Schoep, Income Maintenance Supervisor DHS – 4008 PMAP Change Request Denied Private Robin Schoep, Income Maintenance Supervisor DHS – 4026 DWP/MFIP Screening Questions Private Robin Schoep, Income Maintenance Supervisor DHS – 4079 CCA Provider Responsibilities and Rights Private Schoep, Income Maintenance Supervisor DHS – 4093 MFIP Employment Services Auth. for Release of Information Private Robin Schoep, Income Maintenance Supervisor DHS – Health Plan Enrollment Form for People 65 or older (MSHO) Private Robin Schoep, Income Maintenance Supervisor DHS – 4125 IMD Request to Change Client Eligibility Private Schoep, Income Maintenance Supervisor DHS – 4145 County Notice of IMD Status Private Robin Schoep, Income Maintenance Supervisor DHS – 4161 DWP Referral to Employment Services Private Robin Schoep, Income Maintenance Supervisor DHS – 4277 LTC down Refund Non-Collection Private Schoep, Income Maintenance Supervisor
DHS – 4300 Request for Worker’s Compensation Info (Fraud) Private Robin Schoep, Income Maintenance Supervisor DHS – 4316 Assessor/Treatment Provider Report Private Schoep, Income Maintenance Supervisor DHS – 4347A MNSURE Important Appeal Rights! Private Robin Schoep, Income Maintenance Supervisor DHS – 4412 MFIP Food Support Checklist Private Robin Schoep, Income Maintenance Supervisor DHS – 4457 Request for Department Resolution of Financial Responsibility Dispute Private Robin Schoep, Income Maintenance Supervisor DHS – 4532 Notice of Denial for Public Assistance Private Schoep, Income Maintenance Supervisor DHS – 4555 Authorization for Release of HC Info Private Robin Schoep, Income Maintenance Supervisor DHS – 4600 Notice of Medical Assistance Overpayment Private Schoep, Income Maintenance Supervisor DHS – 4621 CS Medical Support Referral Private Robin Schoep, Income Maintenance Supervisor DHS – 4759 Special Needs/ Pooled Trust Referral Private Robin Schoep, Income Maintenance Supervisor DHS – 4794 CCAP Change Report Form Private Robin Schoep, Income Maintenance Supervisor DHS - 4796 MHCP Change Report Form Private Robin Schoep, Income Maintenance Supervisor DHS – 4834 Expedited SNAP Evaluation Form Private Robin Schoep, Income Maintenance Supervisor DHS – 4841 Authorization to Request Birth Records Private Robin Schoep, Income Maintenance Supervisor DHS – 4843A MHCP Proof of U.S. Citizenship Statement by Applicant/Enrollee Private Schoep,
DHS – 5181 Lead Agency Case Manager/Worker Communication Form Private Robin Schoep, Income Maintenance Supervisor DHS – 5190 CCAP Licensed Provider Registration and Acknowledgment Private Schoep, Income Maintenance Supervisor DHS – 5191 CCAP Licensed Exempt Provider Registration & Acknowledgement Private Robin Schoep, Income Maintenance Supervisor DHS – 5192 CCAP Non-Licensed Provider Registration & Acknowledgment Private Schoep, Income Maintenance Supervisor DHS – 5192A Health and Safety Resource List for Parents and Legal Non-Licensed Providers Private Robin Schoep, Income Maintenance Supervisor DHS – 5193 CCAP Authorization for Release of Background Private Robin Schoep, Income Maintenance Supervisor DHS – 5223 Combined Application Form Private Robin Schoep, Income Maintenance Supervisor DHS – 5223C CAF Addendum Private Robin Schoep, Income Maintenance Supervisor DHS – 5223D Combined Application – Child Care Addendum Private Robin Schoep, Income Maintenance Supervisor DHS – 5223E Minnesota Transition Application Form Private Robin Schoep, Income Maintenance Supervisor DHS – 5223F SNAP Application for Seniors Private Robin Schoep, Income Maintenance Supervisor DHS – MDHS Combined Application Form Household Member Supplement Private Robin Schoep, Income Maintenance Supervisor DHS – 5243 MEC2 Provider Tax Info Change Request Private Robin Schoep, Income Maintenance Supervisor DHS – 5274 CCAP Redetermination For Private Robin Schoep, Income Maintenance Supervisor DHS – Affidavit of Service Private Robin Schoep,
Income Maintenance Supervisor DHS – 5290E Judgment of Operation of Law Private Robin Schoep, Income Maintenance Supervisor DHS – 5290H Affidavit of Service by Mail Private Schoep, Income Maintenance Supervisor DHS – 5367 CCAP Parent Acknowledgement When Choosing a Non-licensed Provider Private Robin Schoep, Income Maintenance Supervisor DHS – 5426A Permission to Share LTC Info Private Robin Schoep, Income Maintenance Supervisor DHS – LTCP Protected Assets Private Robin Schoep, Income Maintenance Supervisor DHS – 5426D LTCP Protected Assets Review Private Robin Schoep, Income Maintenance Supervisor DHS – 5426E LTCP Update Insurance Private Robin Schoep, Income Maintenance Supervisor DHS – 5492 MHCP Return Proofs Private Robin Schoep, Income Maintenance Supervisor DHS – 5523 CCAP Billing Form Private Schoep, Income Maintenance Supervisor DHS – 5532 MHCP Annuity Data Worksheet Private Schoep, Income Maintenance Supervisor DHS – 5576 Combined Six-Month Report Private Robin Schoep, Income Maintenance Supervisor DHS – Combined Six-Month Report Supplement for Cash Private Robin Schoep, Income Maintenance Supervisor DHS – 5590 LTC Case Checklist Private Robin Schoep, Income Maintenance Supervisor DHS – 5675 (Fiscal) Electronic Claims Payment Affidavit Private Robin Schoep, Income Maintenance Supervisor
DHS – 5779 Medical Coverage for Child Receiving Adoption Assistance Private Schoep, Income Maintenance Supervisor DHS – MA for Enrollees who have a Spend down or Waiver Obligation Private Robin Schoep, Income Maintenance Supervisor DHS – 5893 Application for Certificate of Clearance for Medical Assistance Claim Private Robin Schoep, Income Maintenance Supervisor DHS – 6020 SNAP E&T Employment Plan Private Schoep, Income Maintenance Supervisor DHS – 6059C Reported Medical Expenses Notice of Action Private Robin Schoep, Income Maintenance Supervisor DHS – 6123 Referral for Disability Determination Private Robin Schoep, Income Maintenance Supervisor DHS – 6124 Authorization to Release Protected Health Info Private Robin Schoep, Income Maintenance Supervisor DHS – 6125 SMRT Disability Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – 6125A State Reviews for Adults Private Schoep, Income Maintenance Supervisor DHS – 6126 SMRT Children’s Disability Worksheet Private Robin Schoep, Income Maintenance Supervisor DHS – 6165A Application For Certificate of Clearance for Medical Assistance Claim – Decree of Descent Private Robin Schoep, Income Maintenance Supervisor DHS – 6165B Certificate of Clearance for Medical Assistance Claim – Decree of Descent Private Schoep, Income Maintenance Supervisor DHS – 6349 Request for Disability Info Private Robin Schoep, Income Maintenance Supervisor DHS – 6349A SMRT Documentation Requirements Private Robin Schoep, Income Maintenance Supervisor DHS – 6349B MHCP – Request for Disability Information for Private Robin Schoep,
Adults w/o Children Income Maintenance Supervisor DHS – 6351 Verification of Subsidized Housing Application Private Robin Schoep, Income Maintenance Supervisor DHS – 6419 CCAP Training Requirements for Legal Non-Licensed Family Providers Private Robin Schoep, Income Maintenance Supervisor DHS – 6475 CCAP Parent Request for In-Home Child Care Private Robin Schoep, Income Maintenance Supervisor DHS – 6670 Health Care Application Transfer Form Private Robin Schoep, Income Maintenance Supervisor DHS – 6696 MNSURE Application for Health Coverage and Help Paying Costs Private Robin Schoep, Income Maintenance Supervisor DHS – 6696A Supplement to MNSURE Application for Health Coverage and Help Paying Costs Private Schoep, Income Maintenance Supervisor DHS – Supplement to the Minnesota Health Care Programs Application (DHS 3417 or 3876) Private Robin Schoep, Income Maintenance Supervisor DHS – 6696C MNSURE Application for Health Coverage and Health Paying Signature Page Private Robin Schoep, Income Maintenance Supervisor DHS – MNSURE Appendix A – Health Coverage from Jobs Private Robin Schoep, Income Maintenance Supervisor DHS – 6749B MFIP Notice of Drug Felon Match Private Robin Schoep, Income Maintenance Supervisor DHS – 6749A GA or MSA Notice of Drug Felon Match Private Robin Schoep, Income Maintenance Supervisor DHS – 4209 MFIP/DWP Employment Plan Private Robin Schoep, Income Maintenance Supervisor DHS – 4209A MFIP/DWP Employment Plan – Employment Private Schoep, Income Maintenance Supervisor DHS – 4209B MFIP/DWP Employment Plan – Job Search Requirements Private Robin Schoep, Income Maintenance Supervisor
DHS – 4209C MFIP/DWP Employment Plan – Unpaid Work Activities Private Robin Schoep, Income Maintenance Supervisor DHS – 4209D MFIP/DWP Employment Plan – Education Private Robin Schoep, Income Maintenance Supervisor DHS – 4209E MFIP/DWP Employment Plan – Family Safety Private Robin Schoep, Income Maintenance Supervisor DHS – 4209H MFIP/DWP Employment Plan –Child Care or Transportation Private Robin Schoep, Income Maintenance Supervisor DHS – 4209I MFIP/DWP Employment Plan – Health Private Robin Schoep, Income Maintenance Supervisor DHS – MFIP/DWP Employment Plan – Housing Private Robin Schoep, Income Maintenance Supervisor DHS – 4209K MFIP/DWP Employment Plan – Personal/Family Activity Private Robin Schoep, Income Maintenance Supervisor DHS – 4209L MFIP/DWP Employment Plan – Legal Issues Private Robin Schoep, Income Maintenance Supervisor DHS – 4209M MFIP/DWP Employment Plan – County/State Social Services Private Robin Schoep, Income Maintenance Supervisor Bank Recovery Notice Private Robin Schoep, Income Maintenance Supervisor CCAP Provider Compliance Policies Private Robin Schoep, Income Maintenance Supervisor County Burial Application Private Robin Schoep, Income Maintenance Supervisor County Burial Approval Notice – Fax to Funeral Home Private Robin Schoep, Income Maintenance Supervisor County Crisis Application Private Robin Schoep, Income Maintenance Supervisor Customer Satisfaction Survey Private Robin Schoep,
Income Maintenance Supervisor Decedent’s Assets Letter to Nearest Relative Private Robin Schoep, Income Maintenance Supervisor DWP Checklist Private Robin Schoep, Income Maintenance Supervisor DWP Initial Benefit Calculation Private Robin Schoep, Income Maintenance Supervisor Health Care Access Adjustment Private Schoep, Income Maintenance Supervisor Health Care Application Letter Private Robin Schoep, Income Maintenance Supervisor How to Apply for Child Care Assistance Private Robin Schoep, Income Maintenance Supervisor How to Apply for Help – Appointment Letter Private Robin Schoep, Income Maintenance Supervisor How to Apply for Help – Cover Letter for Application Packet Private Robin Schoep, Income Maintenance Supervisor Legal Non-Licensed CCAP Providers – Health and Safety Information Private Robin Schoep, Income Maintenance Supervisor Legal Non-Licensed CCAP Providers – General Eligibility/Payment Information Private Robin Schoep, Income Maintenance Supervisor Legal Non-Licensed CCAP Providers – Notice of Background Study Private Schoep, Income Maintenance Supervisor Non-Licensed CCAP Providers – Renewal Letter Private Schoep, Income Maintenance Supervisor Medical Expense Reimbursement Claim Form Private Robin Schoep, Income Maintenance Supervisor MFIP Assessment Worksheet Private Robin Schoep, Income Maintenance Supervisor