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Printable application forms for health care programs

If you want to apply for Minnesota Health Care Programs (MHCP) on paper, it's important to use the correct application form. The form to use depends on your health care needs. For most people, the easiest way to apply for coverage is online at MNsure, unless you are in one of the population groups that needs to use one of the other forms listed on this page.

If you need help deciding which form to complete, contact your county or tribal office or DHS Health Care Consumer Support.

MNsure Application for Health Coverage and Help Paying Costs DHS-6696 (PDF) 
Use this form or apply online at MNsure to apply for the following programs and help:

  • Medical Assistance (MA)
  • MinnesotaCare
  • A tax credit and payment assistance to lower your cost for coverage

This form is also available in these languages:

MHCP Application for Certain Populations DHS-3876 (PDF) 
Use this form to apply for MA, including Medicare Savings Programs, if you meet any of these criteria:

  • You are 65 years old or older.
  • You are asking for help with only Medicare costs.
  • You are applying for a child in foster care.
  • You are 21 years old or older with no dependents and have Medicare coverage.
  • You receive Supplemental Security Income (SSI).
  • You are applying for Medical Assistance for Employed Persons with Disabilities (MA-EPD).

MHCP Application for Payment of Long-Term-Care Services DHS-3531 (PDF) 
Use this form to apply for MA payment of long-term-care services. Long-term-care services include nursing home care and services in your home through a waiver program.

Minnesota Family Planning Program Application DHS-4740 (PDF) 
Use this form to apply for coverage of family planning services only.

This application is also available in Spanish: Spanish - Minnesota Family Planning Program Application DHS-4740 (PDF).

MHCP Application and Renewal for Breast and Cervical Cancer Coverage DHS-3525 (PDF) 
Use this form to apply for MA if you have breast or cervical cancer and you were screened by the Sage Screening Program or the Screen Our Circle Program.

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