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Printable application forms
If you cannot open a form, contact us to have an application sent to you.
MNsure Application for Health Coverage and Help Paying Costs (DHS-6696) (PDF) - Use this form to apply for Medical Assistance (MA) including Medicare Savings Programs, MinnesotaCare, or for a tax credit and payment assistance to lower your cost for coverage.
Minnesota Health Care Programs Application for Certain Populations (DHS-3876) (PDF) - Use this form to apply for Medical Assistance (MA) including Medicare Savings Programs if everyone in the household is:
Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS-3531) (PDF) - Use this form to apply for Medical Assistance (MA) payment of long-term care services. Long-term care services include nursing home care and services in your home through a waiver program.
Asset Assessment form (DHS-3340) (PDF) - Complete this form if you are married and expect to receive at least 30 consecutive days of long-term care services. Your county worker uses this information to determine how many assets your spouse can keep if he or she remains in the home.
Minnesota Family Planning Program application (DHS-4740) (PDF) - Use this form to apply for coverage of family planning services only.
Medical Assistance for Breast or Cervical Cancer application (DHS-3525) (PDF) - Use this form to apply for Medical Assistance (MA) if you have breast or cervical cancer and you were screened by the Sage Screening Program.
For those who speak little or no English: The Minnesota Health Care Programs Member Help Desk provides free interpreter services. Contact the help desk at 651-431-2670 or 800-657-3739 for help.
The applications below are for basic Minnesota Health Care Programs coverage. The department looks at information it has and information collected from other community resources once a year to decide if these forms need to be translated. Contact DHS LEP for more information about translated forms.
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