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MFPP forms, documents and resources

Use only the Minnesota Family Planning Program (MFPP) approved forms and documents available on eDocs and through MN–ITS.

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

Certified providers determining presumptive eligibility for MFPP

Give the MFPP Application (DHS-4740) (PDF) to people who want to enroll in MFPP. Mail or fax the completed MFPP application and copies of any proofs collected when presumptive eligibility is determined to:

Minnesota Department of Human Services
PO Box 64960
St. Paul, MN 55164-0960
Fax 651-431-7532

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 4739A)
  • MFPP Short-Term Denial (DHS 4739B)
  • MFPP Rx Form – Fax short-term approval letters and Rx to pharmacies (front and back)

Other resources

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