Forms and Applications

Applications and Forms

• Application for Health Coverage and Help Paying Costs - DHS-6696-ENG (PDF)
• Application for Health Coverage - DHS-6741 (PDF)
• Broker Case Status Request Form (Excel)
• Employer Health Coverage form-Appendix A (PDF) (for employees who enroll in individual coverage and whose employer offers small group coverage)

Application Changes and Special Enrollment Periods

Please see the Helping Consumers section for information on these and other topics.

Submitting Forms to MNsure

The following documents should NOT be submitted to the Broker Service Line via secure email. Follow the appropriate guidance on how and where to submit these documents:

• Account Request Form (PDF)
• Appeals forms
• Appendix A forms
• Authorized representative forms (brokers should not be designated as authorized rep for a consumer)
• Eligibility verifications
• FTI forms
• Paper applications
• Special enrollment period (SEP) verifications