Special Needs or Pooled Trust Referral (DHS-4759)

Follow these instructions for the DHS-4759 to refer a special needs trust or pooled trust to DHS.

1. Enter today’s date

At the top of the form, enter today’s date.

2. Enter information about the MA member

Enter the Medical Assistance (MA) member’s name, Social Security number and PMI number.

3. Enter your agency’s contact information

Enter your agency’s name, the servicing agency (if different than your agency) and your full name, phone number and email.

4. Enter information about the trust

Provide the name of the trust, whether there is a copy of the trust in the MA member’s case file and the trustee’s name, phone number and address.

5. Attach a copy of the trust

Ensure you have a digital copy of the trust you can send with the form.

6. Send the form and a copy of the trust DHS

Send a completed DHS-4759 and a copy of the trust via encrypted email or SIR Web Mail to DHS.SRUtrusts@state.mn.us