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Rule 25 Eligibility Application

  1. Are you a Crow Wing County Resident?

  2. If you don't have one, just write "none."

  3. Have you had a previous Chemical Health Assessment/Rule 25?

  4. Who referred you for a Rule 25?

  5. Do you have an open case with Child Protection?

  6. Is this assessment for

  7. Are you currently in treatment?

  8. Do you have Medical Assistance (MA) or Minnesota Care?

  9. Do you have private insurance or a PMAP, HMO coverage (Medica, Health Partners, ect.)?

    (please fill out the information below)

  10. Marital Status:

  11. (Please provide the two most recent proofs of income at the time of assessment.)

  12. Do you and/or your spouse receive earned income?

    Include employment, tips, commission, other, etc.

  13. Per

  14. Are you and/or your spouse on any assistance programs?

    General Assistance (GA), Social Security (SSI, RSDI)

  15. Do you recieve child support or any other income?

    Inheritance, unemployment, royalties, investment dividends, etc

  16. Per

  17. Do you pay any child support?

  18. Per

  19. Per

  20. (By selecting and providing us with the contact information below, you are authorizing us to contact you with private information via any of the ways you have authorized.)

  21. You will be asked to sign a copy of this form at the time of your assessment.

  22. Crow Wing County does not discriminate on the basis of race, color, national origin, sex, religion, age and handicapped status in employment or the provision of services.

  23. By submitting your email address you agree to communicate with Crow Wing County via e-mail.

  24. Verifications:

  25. Eligibility Determination:

  26. Leave This Blank:

  27. This field is not part of the form submission.