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All forms are in Adobe PDF format.  If you cannot open a form, contact us to have an application mailed to you.
Minnesota Health Care Programs application (PDF)
Use this form to apply for basic Medical Assistance (MA), MinnesotaCare, or Medicare Savings Programs
Minnesota Health Care Programs Application for Payment of Long-Term Care Services (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 (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 will use this information to determine how many assets can be kept by your spouse remaining in your home.
Minnesota Family Planning Program application (PDF)
Use this form to apply for coverage of family planning services only.
Medical Assistance for Breast or Cervical Cancer application (PDF)
Use this form if you have breast or cervical cancer and you were screened by the Sage Screening Program
MinnesotaCare for Volunteer Firefighters and Ambulance Attendants (PDF)
Use this application for a volunteer firefighter or ambulance attendant only. More information about the MVFAA program is online.
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For those who speak little or no English: Applicants may call the toll-free phone numbers below to reach someone who speaks their language (live or voicemail). The multilingual referral line representative will then contact the appropriate county or state office and ask them to contact the applicant. The county or state office will provide meaningful access accordingly. The applications below are for basic Minnesota Health Care Programs coverage. The department will evaluate the need to translate these forms annually using information collected on its own and other community resources. Contact DHS LEP for more information about translated forms. |
 Arabic, 1-800-358-0377
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The health care application (DHS-3417) is no longer translated into Arabic. |
 Hmong, 1-888-486-8377
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Application in Hmong (PDF) |
 Khmer (Cambodian), 1-888-468-3787
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The health care application (DHS-3417) is no longer translated into Khmer. |
 Lao, 1-888-487-8251
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The health care application (DHS-3417) is no longer translated into Lao. |
 Oromo, 1-888-234-3798
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The health care application (DHS-3417) is no longer translated into Oromo. |
 Russian, 1-888-562-5877
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Application in Russian (PDF) |
 Serbo-Croatian (Bosnian), 1-888-234-3785
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The health care application (DHS-3417) is no longer translated into Serbo-Croatian. |
 Somali, 1-888-547-8829
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Application in Somali (PDF) |
 Spanish, 1-888-428-3438
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Application in Spanish (PDF) |
 Vietnamese, 1-888-554-8759
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Application in Vietnamese (PDF) |
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