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DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS), page 1
Very Complex · 95/100Form Complexity Index

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What this form asks for

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DHS-6696-ENG is Minnesota’s multi-page health coverage application used to collect household, tax filing, residency, citizenship/immigration, and income information needed to determine eligibility for public health programs and related financial assistance. It is important because the information you provide is used to verify identity and income, assess program eligibility (including MA and MinnesotaCare), and coordinate coverage with any existing insurance. The form also includes required consents and acknowledgments (privacy, rights/responsibilities, and tax information use) that affect verification and renewal of benefits.
Fillable fields601
Pages13
Sections146
Tables and lists7
Questions that depend on earlier answers289
Form Complexity IndexVery Complex, 95/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Person 1 identity fields completeness (name, DOB, sex, marital status)

Validates that Person 1 (the required contact person) has First Name, Last Name, Date of Birth, Sex, and Marital Status completed. These fields are foundational for eligibility determination, identity matching, and downstream notices. If any are missing or invalid, the submission should be flagged as incomplete and routed for correction before eligibility processing continues.

Date format and calendar validity for all date fields

Checks that every date provided (e.g., DOB, due date, pregnancy end date, move date, emergency begin/end, date of entry, temporary absence dates, military tour end date, signature date) is in MM/DD/YYYY format and represents a real calendar date. This prevents parsing errors and incorrect eligibility timelines. If validation fails, the system should reject the specific field(s) and request corrected dates.

Age-dependent legal control question consistency

Validates that the 'under legal control of a parent' question is answered only when the person is under 18 based on DOB, and is not answered (or is ignored) for adults. This ensures the form logic is followed and avoids contradictory household/guardianship assumptions. If an adult has this answered or a minor is missing it, the record should be flagged for review or the applicant prompted to correct.

Social Security Number (SSN) structure and conditional requirement logic

If SSN is provided, validates it is exactly 9 digits (allowing standard formatting like XXX-XX-XXXX) and not an obvious invalid value (e.g., all zeros). If the applicant indicates they have an SSN, the SSN field must be present; if they indicate no SSN, then either 'applied for SSN' must be answered or a valid reason must be selected when applicable. Failures should trigger a hard error when SSN is required by the applicant’s own selection, or a soft stop when optional but inconsistent.

Homeless indicator vs address requirements (including Safe at Home rules)

If 'homeless' is checked, validates that the county where the person usually stays is provided and that a full home street address is not required. If not homeless, validates that Home Address includes street, city, state, ZIP, and county, and that the home address is not a PO Box. If the Safe at Home Program is used, validates that home address contains at least county and ZIP and that the Safe at Home address is placed in Mailing Address; failures should prompt correction to prevent misdirected mail and privacy risks.

State and ZIP code validation for Minnesota residency fields

Validates that state values are valid US state abbreviations and that ZIP codes are 5 digits (or ZIP+4 if allowed), and cross-checks that Minnesota residency questions are consistent with a Minnesota address when coverage is requested. This reduces eligibility errors tied to residency and county-based administration. If the address is outside MN while the applicant claims MN residency, the submission should be flagged for manual review or additional proof.

And 10 more checks
  • Phone number format and contact preference dependency
  • Language and interpreter request consistency
  • Tax filing intent and spouse/dependent sub-question logic
  • Marital status vs tax filing selections consistency
  • Pregnancy details completeness and plausibility
  • Minnesota residency question set completeness when applying for coverage
  • Citizenship/immigration section branching and document field validation
  • Medical emergency and MA retroactive coverage date logic
  • Employment selection vs required job/income fields
  • Income amount, frequency, and numeric constraints validation

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How to Fill Out DHS-6696-ENG Online for Free in 2026

What the AI walks you through.

  1. Review Step 1 rules to determine who must be included in the household (tax household and people living with you), and note whether anyone is pregnant or in the Safe at Home Program.
  2. Complete Step 2 for Person 1 (the contact person): personal details, SSN/immigration (if applying), addresses, contact preferences, tax filing plans, pregnancy questions, and Minnesota residency questions.
  3. Add each additional household member by completing Step 2 for Person 2, Person 3, etc. (make copies of the additional-person pages if needed), including whether each person is applying for coverage.
  4. Enter job and income details for each person as applicable (employment, self-employment, seasonal income, other income, and adjustments), and provide projected annual income information when requested.
  5. Complete Step 3 (current coverage, offers of employer coverage, accident/injury care) and any required appendices (e.g., Appendix A for job-based coverage offers, Appendix B for American Indian/Alaska Native status, Appendix C for an authorized representative).
  6. Complete Step 4 and Step 5 household details and changes (military service, incarceration, foster care, disability/long-term care needs, temporary absence from Minnesota, and recent changes affecting eligibility).
  7. Complete Step 6 consents and acknowledgments, sign and date the application, then submit the signed form and any appendices by fax, mail, or in person as instructed in Step 8.

Common Mistakes in Completing DHS-6696-ENG

The ones the AI is built to catch.

Including the wrong people in the household (Step 1)
Applicants often list everyone who lives in the home, but Step 1 is based on tax relationships and specific household rules (spouse, children under 19, tax dependents, etc.). This can inflate or shrink household size and lead to incorrect eligibility results, wrong program placement, or requests for clarification. To avoid this, follow the “DO include/DO NOT include” bullets exactly and cross-check against who will be on the next federal tax return (including dependents who don’t live with you).
Not listing tax dependents because they are not seeking coverage (Step 2 Q24b / Person 2 Q8b)
A very common error is leaving off dependents when the applicant thinks “they already have insurance” or “they aren’t applying.” The form explicitly says dependents must be listed if claimed on the tax return, even if they are not applying for coverage. Missing dependents can change household size and financial assistance calculations, causing delays and incorrect determinations; list all dependents by name and ensure they appear somewhere in Step 2.
Mixing up “applying for coverage” vs. “included on the application” (Step 2 Q26 / Person 2 Q10)
People frequently answer “No” to applying for coverage and then stop providing information that is still needed because the person is part of the household/tax unit. While SSN/immigration details may be optional for non-applicants, household composition and tax-filing information still affects eligibility for others. To avoid problems, decide separately: (1) who must be included in the household and (2) who is actually applying for coverage, and complete the required sections accordingly.
Entering SSN information incorrectly or leaving the SSN section inconsistent (Step 2 Q5 / Person 2 Q6)
Applicants often check “Yes” for having an SSN but leave the SSN blank, transpose digits, or forget to answer whether they applied for an SSN and the reason if they have not. This can prevent electronic verification of income/identity and trigger manual follow-up requests. To avoid this, copy the SSN directly from the Social Security card (or official document), complete the “applied for SSN” question, and only choose the “not applying and choose not to answer” option if the person truly is not applying.
Using a PO Box as the home address or not following Safe at Home instructions (Step 2 Q7a and Safe at Home note)
The form states not to put a PO Box in the Home Address field, but many applicants do because they receive mail there. This can cause residency/address verification issues and delays, especially if the county is missing or mismatched. Use a physical home address for Q7a, put the PO Box only in Mailing Address (Q12), and if enrolled in Safe at Home, provide only county and ZIP for the home address and put the Safe at Home address in the mailing section.
Leaving contact preferences incomplete (phone type, email, interpreter, method of contact) (Step 2 Q18–Q22)
Applicants often provide a phone number but don’t mark whether it is cell/home/work, or they select email contact but forget to write the email address. Others indicate they need an interpreter but don’t clearly specify the preferred spoken language. This leads to missed notices, inability to reach the applicant, and processing delays; always label phone types, provide a valid email if selected, and complete language/interpreter fields consistently.
Incorrect tax filing answers (joint filing, MFS due to abuse/abandonment, or being claimed as a dependent) (Step 2 Q24 / Person 2 Q8)
Tax questions are frequently misunderstood, especially “Will you be claimed as a dependent?” and the special Married Filing Separately exception for domestic abuse/spousal abandonment. Wrong answers can change eligibility for MinnesotaCare/MA and premium tax credits, and may create conflicts when data matches with IRS records. To avoid this, answer based on the upcoming tax year plan, confirm whether anyone else will claim you, and only mark the MFS abuse/abandonment option if it truly applies.
Reporting wages as net pay or choosing the wrong frequency (Step 2 Q35/Q37)
Many people enter take-home pay instead of “amount before taxes,” or they select a frequency that doesn’t match the amount (e.g., entering a biweekly amount but checking “monthly”). This can significantly distort annual income calculations and lead to incorrect eligibility or repayment risk later. Use gross pay from pay stubs, pick exactly one frequency that matches the number, and if income varies, use the “Yearly” option with a realistic 12-month estimate as instructed.
Omitting employer details or confusing EIN with other numbers (Step 2 Q34/Q36 and job change section Q33)
Applicants often leave employer name/address blank, write a supervisor’s name instead of the legal employer name, or enter the wrong identifier (using a phone number or state tax ID instead of the EIN). Missing or incorrect employer information can slow verification and create follow-up requests. To avoid this, use the employer name exactly as shown on the paycheck/W-2, include the full address if available, and copy the EIN from a W-2 or official payroll document (or leave it blank if unknown rather than guessing).
Listing income types that the form says NOT to include (Step 2 Q40/Q24 for Person 2)
People commonly list child support or SSI under “Other income” because they assume all money received must be reported. The form explicitly says not to list child support, SSI, certain nontaxable veteran payments, and ABLE account money in this section, and including them can inflate income and reduce benefits incorrectly. Follow the note carefully, and when in doubt, only report items that would appear as taxable income on IRS Form 1040 (unless the form specifically asks for it).
Misreporting Social Security benefits by using the net deposit amount (Step 2 Q40 Social Security benefits)
Applicants often enter the amount deposited after Medicare premiums or other deductions, but the form requires the gross amount before deductions and includes both taxable and nontaxable Social Security benefits. Using the net amount can understate income and later cause eligibility corrections or overpayment issues. Use the SSA award letter or annual SSA-1099 to report the gross monthly benefit amount.
Skipping past-coverage and prior-month medical assistance questions (Step 3 Q1 and Step 2 Q32/Person 2 Q16)
Applicants frequently answer current coverage questions incompletely (missing policyholder DOB, group number, covered members) or overlook the option to request help with medical bills from the past three months. Incomplete insurance details can delay coordination of benefits, and missing the past-three-month request can mean losing potential retroactive coverage. Carefully complete all policy fields and covered-person lists, and if you had recent medical bills, answer the MA past-three-month questions and select the correct months.

Frequently Asked Questions About DHS-6696-ENG

 

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How does the AI fill out DHS-6696-ENG?
You answer a few questions in plain words, or upload your insurance card. The AI reads what you give it and puts each answer into the right field of DHS-6696-ENG, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is DHS-6696-ENG to fill out?
DHS-6696-ENG has a Form Complexity Index of 95 out of 100, in the very complex tier: 601 fillable fields across 13 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is this application (DHS-6696) used for?
This application is used to apply for Minnesota health care coverage and help paying for coverage costs, including programs like Medical Assistance (MA) and MinnesotaCare. It also helps determine eligibility for financial assistance based on household size and income.
Who should I include on the application in Step 1?
Include everyone who lives with you and anyone on your tax return (even if they don’t live with you). You should also include your spouse and children under 19 who live with you, plus any dependents you claim.
Who should I NOT include on the application?
Do not include adult children (19+) unless you expect to claim them as tax dependents, and do not include an unmarried partner unless you have children together or file taxes together. Roommates and other non-tax-related household members generally file their own application.
Do I have to list people who are not applying for health coverage?
Yes, you may still need to list them if they are part of your household or tax family because household size and income affect eligibility. If someone is not applying, they do not have to provide an SSN or immigration status.
Do I have to provide a Social Security number (SSN) for everyone?
No—SSNs are optional for people who are not applying for coverage. However, providing SSNs (when available) can speed up processing because they are used to verify income and other eligibility information.
What if I don’t have an SSN or I’m not eligible for one?
You can indicate that you do not have an SSN and select the reason (for example, noncitizen not eligible or not authorized to work). The form also asks whether you have applied for an SSN.
What address should I use if I’m in Minnesota’s Safe at Home Program?
If you are in the Safe at Home Program, you do not need to provide your full home address—only your county and ZIP code in the Home Address section. Put your Safe at Home Program address in the Mailing Address section.
What if I’m homeless—how do I complete the address section?
Check the box that says you are homeless and provide the county where you usually stay. You can still provide a mailing address if you have one where you can receive mail.
How do I answer the tax filing questions in Step 2 (Question 24/8)?
Answer whether you plan to file a federal tax return next year, whether you will file jointly, and whether you will claim dependents or be claimed as a dependent. If you claim dependents, you must list them on the application even if they are not applying for coverage.
I’m pregnant (or someone in my household is). Do I need to report it?
Yes—check the pregnancy box and complete the pregnancy questions for the person who is pregnant, including due date and number of babies expected. The form notes that applications may be processed faster if someone in the household is pregnant.
Do I have to answer the ethnicity and race questions?
No, these questions are optional and are not required to get health care coverage. They are used to help identify health disparities and improve care.
What if I’m not a U.S. citizen—can I still apply?
Yes, health care coverage may still be available even if you are not a U.S. citizen or do not have an immigration status listed. If you have an eligible immigration status, you can provide details like A-number/ID number, entry date, and document information.
What does it mean to request help for a medical emergency (Questions 30/14)?
This is for people who are not U.S. citizens/nationals and want help paying for a medical emergency. You’ll be asked to provide the begin and end dates of the emergency (if it has ended).
Can I get help paying medical bills from the past three months?
Yes—if you want Medical Assistance (MA) to help pay medical bills from the past three months, answer “Yes” and select which months you want help for. You’ll also be asked whether your household and income information was the same during those months.
How do I report income if my hours or pay change from week to week?
For wages, you can choose a frequency (hourly, weekly, monthly, yearly, etc.), and if your hours/wages vary, the form instructs you to enter the total wages you expect for the next 12 months using the “Yearly” option. Be sure to list taxable wages and tips before taxes and exclude certain pre-tax deductions.
What income should I NOT list in the “Other income” section?
Do not list child support, nontaxable veteran’s payments, money from an ABLE account, or Supplemental Security Income (SSI). The form also clarifies that SSI is not a Social Security benefit.
What are “adjustments to income,” and why should I include them?
Adjustments to income are certain expenses that can be subtracted from gross income on a federal tax return (like student loan interest or some self-employment deductions). Reporting them may lower the cost of your health coverage if you qualify.
What if someone in my household has job-based insurance available but isn’t enrolled?
In Step 3, you must answer whether anyone is offered health insurance from a job even if they are not enrolled (including coverage offered through a spouse or parent). If yes, you must complete Appendix A.
How do I submit the completed application, and where do I send it?
You can submit the signed application by fax (for faster processing), by mail using the enclosed envelope, or in person. Send it to your county or tribal agency or DHS Health Care Consumer Support using the addresses and fax numbers listed on Attachment B.
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