Minnesota Family Planning Program (MFPP) forms, documents and resources

Use only the MFPP approved forms and documents available on eDocs and through MN–ITS.

To apply to be a certified MFPP provider, refer to the Certified MFPP Provider Application packet (DHS-4773) (PDF).

Certified providers determining presumptive eligibility for MFPP

Give the MFPP Application and Renewal Form (DHS-4740) (PDF) to people who want to enroll in MFPP. Submit completed MFPP presumptive eligibility, applications, renewals, and copies of any proofs through the Health Care Consumer Support (HCCS) Document Portal for Partners and Providers or U.S. Postal Service.

Health Care Consumer Support (HCCS) Document Portal for Partners and Providers

MFPP providers can use the HCCS Document Portal for Partners and Providers to electronically submit presumptive eligibility forms, health care applications, and other documents to HCCS. Refer to the following links to the portal and resources for user instructions:

Forms available only in MN–ITS

Log in to MN–ITS to access the following forms when determining presumptive eligibility:
  • MFPP Short-Term Approval (DHS-5701A)
  • MFPP Short-Term Denial (DHS-5701B)
  • MFPP Rx Form – Fax short-term approval letters and Rx to pharmacies (front and back)

Other resources