Application forms

Apply online
Application help in your area (PDF)

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
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 Payment of Long-Term Care Services
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
- 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
Use this form to apply for coverage of family planning services only.

Medical Assistance for Breast or Cervical Cancer application
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 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

The health care application (DHS-3417) is no longer translated into Arabic.

Image: Hmong language Hmong, 1-888-486-8377

Application in Hmong (PDF)

Image: Khmer (Cambodian) language Khmer (Cambodian), 1-888-468-3787

The health care application (DHS-3417) is no longer translated into Khmer.

Image: Lao language Lao, 1-888-487-8251

The health care application (DHS-3417) is no longer translated into Lao.

Image: Oromo language Oromo, 1-888-234-3798

The health care application (DHS-3417) is no longer translated into Oromo.

Image: Russian language Russian, 1-888-562-5877

Application in Russian (PDF)

Image: Serbo-Croatian (Bosnian) language Serbo-Croatian (Bosnian), 1-888-234-3785

The health care application (DHS-3417) is no longer translated into Serbo-Croatian.

Image: Somali language Somali, 1-888-547-8829

Application in Somali (PDF)

Image: Spanish language Spanish, 1-888-428-3438

Application in Spanish (PDF)

Image: Vietnamese language Vietnamese, 1-888-554-8759

Application in Vietnamese (PDF)


Rate/Report this page   Report/Rate this page