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Insurance Information <br />16. Are you receiving Medical Assistance or Minnesota Care benefits?: Yes <br />Comments: <br />17. If yes, are you enrolled in a health care plan such as Health Partners or U-Care? <br />Yes No <br />If yes, please contact your health care plan and ask for a chemical pendency assessment. This is a covered <br />benefit. If no, please continue.' <br />18. Do you have any private health insurance or HMO coverage? _Yes No <br />If yes, please provide the following information OR a copy (front & back) of your insurance card. <br />if no, please skip to line 28. <br />19. Company Name: <br />20. Company Address: <br />21. Policy Number: <br />22. Policy Holder Name: <br />23. Policy Holder Address: <br />24. Group Name ,/ Number: <br />25. Contact Person Name/Tel# <br />26, Coverage Type Limitations / Co -payments <br />Outpatient <br />Inpatient <br />Comments: <br />27. Other: <br />Telephone 4:. <br />NOTE: <br />If you do not have any medical insurance apply online at WWW.MNSURE.ORG. <br />Adults with no children can call 763-422-7200 (Government Center, 4th Floor). <br />Adults with children or minors can call 763-717-7700 (Blaine Human Services Center, 4`"` Floor). <br />Income Information - Applicant <br />28. Are you currently employed or have unemployment income? _Yes _ No <br />29. If yes, what is your average weekly amount: $ Employer: <br />(If yes, please provide copies of your 2 most recent pay stubs or self-employment records or <br />copies of your most recent tax returns or a statement of employment & income signed by your <br />employer) <br />30. If you are not currently employed, what was your last date of employment: <br />(If your job ended less than 3 months ago, please provide a statement from the former <br />employer showing your last date of work or COBRA statement or termination notice). <br />