Application forms

Apply online
FAQs about applying

County offices

MinnesotaCare

Veterans services
Apply for other assistance

Search for more e-forms

Printable application forms

All forms are in Adobe PDF format. DHS image 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) - 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) - Use this form to apply for Medical Assistance (MA) including Medicare Savings Programs if everyone in the household is:

  • Age 65 or older.
  • Only asking for help with Medicare costs.
  • A child in foster care.
  • Over age 21 with no dependents and has Medicare coverage.
  • Receiving Supplemental Security Income (SSI).
  • Applying for Medical Assistance for Employed Persons with Disabilities (MA-EPD).

  • Minnesota Health Care Programs Application for Payment of Long-Term Care Services (DHS-3531) - 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) - 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) - Use this form to apply for coverage of family planning services only.

    Medical Assistance for Breast or Cervical Cancer application (DHS-3525) - 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: Applicants may call the phone numbers below to talk to someone who speaks their language. The multilingual referral line staff person will contact the county or state office and ask them to contact the applicant.

    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.

    Language and phone number Information
    Arabic language Arabic, 1-800-358-0377 The health care application is no longer translated into Arabic.
    Hmong language Hmong, 1-888-486-8377 Application in Hmong (PDF)
    Khmer languageKhmer (Cambodian), 1-888-468-3787 The health care application is no longer translated into Khmer.
    Lao language Lao, 1-888-487-8251 The health care application is no longer translated into Lao.
    Oromo language Oromo, 1-888-234-3798 The health care application is no longer translated into Oromo.
    Russian language Russian, 1-888-562-5877 Application in Russian (PDF) (DHS-3525)
    Serbo-Croatian (Bosnian) language Serbo-Croatian (Bosnian), 1-888-234-3785 The health care application) is no longer translated into Serbo-Croatian.
    Somali language Somali, 1-888-547-8829 Application in Somali (PDF)
    Spanish language Spanish, 1-888-428-3438 Application in Spanish (PDF)
    Vietnamese language Vietnamese, 1-888-554-8759 Application in Vietnamese (PDF)

    Rate/Report this page   Report/Rate this page