Health Care Renewal Notice Page 27
Download a blank fillable Health Care Renewal Notice in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Care Renewal Notice with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46Reset Form
Attachment C
Agency Name
Address Line 1
Address Line 2
City, State Zip
Reference Number:
Select to Enter IC Number.
Case Name
Address Line 1
Address Line 2
City, State Zip
Health Care Renewal Notice
We have renewed health care coverage for members of your household. This notice is for the
members of your household listed below.
Health Care Results
Household member name.
MNsure ID Number:
Select to enter ID.
Effective Date
Action
Coverage Type
Renewed
You remain eligible for the coverage type shown above, and your coverage will continue. [Code
of Federal Regulations, title 42, sections 431.210 and 435.913; Minnesota Statutes, section
256L.04 (MinnesotaCare)]
If you are eligible for MinnesotaCare and you have a premium amount due, you must make a
payment for coverage to continue. Your coverage continues on the first day of the month after
you make your payment. You will receive your premium notice in the mail, if you have not
already. Send the payment to us as soon as you can.
When should I tell you if I have a change?
Report changes within 10 days of the change. Tell us about all changes, including changes in:
• Where you live
• Who lives with you
• Who you list as a dependent on your income taxes
• Income
• Starting or stopping other health insurance
• Incarceration status
• Minnesota residency
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business