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OFFICES TO BE CLOSED
County Offices Will Be Closed Monday, July 4th in Observance of Independence Day
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Rule 25 Eligibility Application
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This form has been modified since it was saved. Please review all fields before submitting.
Date of Request
*
Date of Request
First Name:
*
Last Name
*
Date of Birth:
*
Social Security No.
Are you a Crow Wing County Resident?
Yes
No
If no, which county do you reside in?
If you do not know your county, click here:
USPS Zip Code Lookup
Type your address into the fields and press submit. Click on "Show Mailing Industry Details."
Address:
*
City
*
Do you have a phone number?
*
Yes
No
Phone:
Please bring in a piece of mail with current address. If you are homeless please give your last permanent address with the dates you resided at that address.
Have you had a previous Chemical Health Assessment/Rule 25?
Yes
No
If yes, date:
Place:
Who referred you for a Rule 25?
Self
Corrections
Court
Other
Other:
Do you have an open case with Child Protection?
Yes
No
If yes who?
Social Worker:
County:
Probation Officer:
Current Charges:
Next Court Date:
Is this assessment for
Alcohol Use or
Other Drug Use
Other:
Are you currently in treatment?
Yes
No
Insurance:
Do you have Medical Assistance (MA) or Minnesota Care?
Yes
No
If yes PMI#:
County:
Do you have private insurance or a PMAP, HMO coverage (Medica, Health Partners, ect.)?
Yes
No
(please fill out the information below)
Insurance Company Name:
Insurance Company Phone Number:
Policy Holder's Name:
ID and Group Number
Please provide a copy of the card.
Household Size
Marital Status:
*
Single
Married
Separated
Divorced
Widowed
Who do you live with? (e.g. parents, spouse, biological children; please do not include unmarried partners or their children.)
Income
(Please provide the two most recent proofs of income at the time of assessment.)
Do you and/or your spouse receive earned income?
*
Yes
No
Include employment, tips, commission, other, etc.
Amount:
Per
Week
Two Weeks
Month
Year
Are you and/or your spouse on any assistance programs?
*
Yes
No
General Assistance (GA), Social Security (SSI, RSDI)
Amount per month:
Do you recieve child support or any other income?
*
Yes
No
Inheritance, unemployment, royalties, investment dividends, etc
Amount:
Per
Week
Two Weeks
Month
Year
Do you pay any child support?
*
Yes
No
Amount:
Per
Week
Two Weeks
Month
Year
Total income, less child support paid:
Per
Week
Two Weeks
Month
Year
How would you like to receive notice of your eligibility for a chemical health Rule 25 Assessment?
(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.)
Select one below:
-- Select One --
Phone
E-mail
Mail
Notify Contracted Treatment Provider
Phone #
E-mail address
Address
Contracted Treatment Provider Fax # or E-mail address
By submitting this form, I certify this information to be accurate to the best of my knowledge and ability.
You will be asked to sign a copy of this form at the time of your assessment.
Crow Wing County reserves the right to terminate treatment immediately if any of the above information is found to be fraudulent.
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.
Please enter your email address, if you would like a return reciept
By submitting your email address you agree to communicate with Crow Wing County via e-mail.
Office Use Only
Date
Time
Verifications:
Photo ID
Proof of Address
Proof of Income
Eligibility Determination:
Eligible
Not Eligible
Authorization # if Eligible
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.
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
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