Form to Request an Appeal
Individuals and employers may use the same appeal request form and process.
Forms for Small Business
Find forms for small business and employees here.
Paper Application Forms for Individuals and Families
If you use a paper application and are found eligible to purchase a qualified health plan, you will not be able to choose your health plan right away. Because of this, we strongly urge you to apply online.
- Subsidized application (PDF)
DHS-6696: This form is used to apply for Medical Assistance (MA), MinnesotaCare, and affordable private health insurance (qualified health plans) with premium tax credits and cost-sharing reductions through MNsure. This form is fillable so you can type in answers, print out the completed application and mail or fax it to us.
- Non-subsidized application (PDF)
DHS-6741: This form is used to apply to purchase a qualified health plan through MNsure without any determination of financial assistance. This form is fillable so you can type in answers, print out the completed application and mail or fax it to us. This fillable PDF form is also available in Hmong, Russian, Somali, Spanish and Vietnamese.
- Account Request Form (PDF)
Use this form if we have been unable to verify your identity electronically.
- Health Coverage from Jobs (Appendix A) (PDF)
Use this form to give us information about people in your household who are eligible for health coverage from a job.
- Application for Certain Populations (PDF)
DHS-3876: This application is for those with special circumstances whose eligibility cannot be determined online through MNsure. Use this form if all the applicants in the household meet at least one of the following criteria: are age 65 or older, requesting help only with Medicare costs, children in foster care, age 21 years or older with no dependents and have Medicare coverage, receiving Supplemental Security Income (SSI), or applying for Medical Assistance for Employed Person with Disabilities (MA-EPD).
Important privacy notice: to protect your privacy, remember to delete any copies of these downloaded forms if you are using a public or shared computer.