DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS) Completed Form Examples and Samples
Explore detailed, filled-out examples and samples of the DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS). Our guide provides completed form scenarios to help you accurately fill out your application for Minnesota health coverage.
DHS-6696-ENG Example – Family with Job Loss
How this form was filled:
In this example, our AI populates the Minnesota Health Care Programs Application (DHS-6696-ENG) for a family of three. The necessary information was extracted from an informal email written by the primary applicant to her sister, a social worker, seeking assistance after a recent job loss. The AI accurately identifies all household members, their relationships, income details, and the change in employment circumstances to complete the form.
Source document used: Email to a Family Member
Hi Sara, Hope you're doing well. I'm writing because I need your social worker brain for a minute. Things are a bit of a mess over here. As you know, Bright Ideas Inc. did a round of layoffs, and I was part of it. My last day was April 25, 2024, so our health insurance ran out at the end of the month. I'm trying to figure out this MNsure application (DHS-6696-ENG) and it's overwhelming. It's for me (Maria Sanchez, born 05/15/1990), my husband David (David Sanchez, born 07/20/1988), and our little guy Leo (Leo Sanchez, born 10/05/2021). We all need coverage. We live at 456 Oak Avenue, St. Paul, MN 55102, in Ramsey County. My cell is the best way to reach me at 651-555-1234, or my email [email protected]. Financially, it's tricky. I'm not getting any income right now, haven't even applied for unemployment yet. David is still doing his freelance graphic design work. It's so unpredictable, but he thinks he'll probably bring in around $40,000 for the whole year. We always file our taxes together as married filing jointly and we'll be claiming Leo, of course. For the race/ethnicity stuff, I'm Mexican American and David is White, which I guess they ask about. We're all U.S. citizens and have SSNs. Is there anything else I need to know? We don't have any other insurance offers, no one's in the military, and thankfully no major disabilities or anything. I'm just worried about not having coverage, especially with Leo. Any advice on filling this thing out would be a lifesaver. Thanks so much, Maria
Information used to fill out the document:
- Applicants: Maria Sanchez, David Sanchez, and Leo Sanchez
- Household Situation: Family of three living at 456 Oak Avenue, St. Paul, MN 55102
- Employment Change: Maria Sanchez was laid off from Bright Ideas Inc. on April 25, 2024
- Income Sources: David Sanchez: Self-employed graphic designer (approx. $40,000/year). Maria Sanchez: Unemployed.
- Tax Status: Married filing jointly, claiming one child (Leo)
- Contact Information: [email protected], 651-555-1234 (Cell)
- Coverage Need: All three family members are applying for health coverage.
What this filled form sample shows:
- Identified all **household members** and their relationships from the narrative.
- Extracted details about a **recent job loss**, including the date and former employer.
- Distinguished between **unemployment and self-employment income** to correctly report financial status.
- Correctly determined **tax filing status** (married filing jointly) and dependents.
- Parsed **address and contact information** and applied it to the primary applicant.
Form specifications and details:
| Use Case: | Family with mixed income (self-employed and unemployed) applying for state health coverage after a job loss. |
| Source Document: | Email to a family member seeking application assistance. |
| Categories: | CAR forms, Minnesota DHS forms, health care forms, MNsure forms, L.A. Care forms, health forms |
| Created: | March 10, 2026 03:44 AM |