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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 local county or Tribal office or Health Care Consumer Support.

Apply online Find your local county or Tribal office Health Care Consumer Support

For most applicants

Most applicants should use the MNsure Application for Health Coverage and Help Paying Costs. This includes people who are applying for:

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

This form is available in these languages:

English (PDF) Español (PDF) Hmoob (PDF) Pусский (PDF) Af Soomaali (PDF) Tiếng Việt (PDF)

If you are 65 or older, Blind or disabled

If you meet any of the criteria below, you should use the MHCP Application for Certain Populations to apply for Medical Assistance, including Medicare Savings Programs:
  • 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).
Download the form (PDF)

For long-term care services

If you need long-term-care services, including nursing home care or services in your home through a waiver program, use the Application for Payment of Long-Term-Care Services.

Download the form (PDF)

For family planning services

If you ONLY need family planning services, use the Minnesota Family Planning Program Application.

This application is available in:

English (PDF) Español (PDF)

For breast or cervical cancer care

If you have breast or cervical cancer and you were screened by the Sage Screening Program or the Screen Our Circle Program, use the Application and Renewal for Breast and Cervical Cancer Coverage.

Download the form (PDF)

Renewal forms

We need to review your information at certain times to see whether you are still eligible for Minnesota Health Care Programs. This review process is called renewal.

If we are not able to automatically renew eligibility, you will get a letter in the mail telling you when you need to complete a renewal, along with a form. If you lose your form, contact your county or Tribal worker or Health Care Consumer Support.

Learn about renewals Find your local county or Tribal office Health Care Consumer Support

For most members

Most members should use the Renewal for Families, Children and Adults form. This includes people who are renewing coverage for:

  • Families with children under age 21
  • Adults without children
Download the form (PDF)

For certain populations

You should use the Renewal for People Receiving Medical Assistance Who Are Age 65 or Older and People Who Are Blind or Have a Disability (MA-ABD) if you meet any of the following:
  • Are 65 years old or older
  • Are Blind or have a disability
  • Are enrolled in a Medicare Savings Program
  • Are enrolled in Medical Assistance with a spenddown
  • Are age 21 or older, have no children and have Medicare coverage
Download the form (PDF)

For long-term care services

If you have long-term-care services, including nursing home care or services in your home through a waiver program, use the Renewal for People Receiving Medical Assistance for Long-Term Care Services (MA-LTC).

Download the form (PDF)

For family planning services

If you ONLY have family planning services, use the Minnesota Family Planning Program Application to renew your coverage.

This application is available in:

English (PDF) Español (PDF)

For breast or cervical cancer care

If you have breast or cervical cancer and you were screened by the Sage Screening Program or the Screen Our Circle Program, use the Application and Renewal for Breast and Cervical Cancer Coverage.

Download the form (PDF)

Other forms

Appeal to State Agency

Application form used to initiate or start a human services appeal of a county or state action. Form may be completed and submitted online.

This form is available in these languages:

English (PDF) Español (PDF) Hmoob (PDF) Pусский (PDF) Af Soomaali (PDF) Tiếng Việt (PDF)

Appeal to State Agency instructions

Instructions for the Appeal to State Agency form (DHS-0033) used to initiate or start a human services appeal of a county or state action.

Download the form (PDF)

Appeal Party Document Submission Form

Form used to submit documents, pictures, audio, and video to the DHS Appeals Division for an existing appeal. Do not use this form to start an appeal. Use DHS-0033-ENG to start a new appeal.

Download the form (PDF)