MINNESOTA GOVERNMENT DATA PRACTICES ACT INVENTORY OF NOT PUBLIC DATA ON INDIVIDUALS Responsible Authority Rae Ann Keeler-Aus Department/Division – Yellow Medicine County Family Service Center, Director Human Services Income Maintenance – Name of Form, Description Record, File, Designee Classification (Purpose, what it collects, in terms understandable by general public) System, or Process Robin Schoep, DHS - 0033 Appeal to State Agency Private Income Maintenance Supervisor Robin Schoep, DHS 0035 State Agency Appeals Summary Private – Income Maintenance Supervisor Robin Schoep, DHS 1609 Nonreceipt/Replacement Affidavit Private – Income Maintenance Supervisor Private Robin Schoep, DHS 1795 SSI Interim Assistance Authorization – Income Maintenance Supervisor Private Schoep, DHS 1795A Interim Assistance Agreement – Income Maintenance Supervisor Private Robin Schoep, DHS 1844 Medical Expenses Request – Income Maintenance Supervisor Private Robin Schoep, DHS 1922B MHCP Health Insurance Information Form (HIIF) – Income Maintenance Supervisor Private Schoep, DHS 2116 Notice to Apply for Other Maintenance Benefits – Income Maintenance Supervisor Private Robin Schoep, DHS 2120 Household Report Form – Income Maintenance Supervisor Private Schoep, DHS 2128 LTC Renewal – Income Maintenance Supervisor Private Robin Schoep, DHS 2136 SNAP Claim Determination Report – Income Maintenance Supervisor Private Schoep, DHS 2146 Auth. for Release of Employment Info – Income Maintenance Supervisor DHS 2237A Medical Service Questionnaire Private Robin Schoep, –
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,
Data_Inventory_-_Income_Maintenance.docx