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G for health care coverage only. Ask the county agency for the Minnesota Health Care Programs Application (DHS-3417). A person with a disability or age 65 or older who may need to move to a nursing home or would like services to stay in your home. Ask the county agency for the Minnesota Health Care Programs Application for Payment of Long-Term Care (DHS-3531) and a Long-Term Care Consultation. How to fill out this form Fill out this form in black or dark blue ink. Complete and turn in t.

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