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MNsure Paper Applications

If you use a paper application and are found eligible to purchase a private health plan, you will not be able to choose your health plan right away. Because of this, we strongly urge you to apply online.

Application WITH financial help (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. This PDF form is also available in Hmong, Russian, Somali, Spanish and Vietnamese.

Application WITHOUT financial help (PDF)
DHS-6741: This form is used to apply to purchase a private 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 PDF form is also available in Hmong, Russian, Somali, Spanish and Vietnamese.

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). This PDF form is also available in Hmong, Russian, Somali, Spanish and Vietnamese.

Account Request Form

MNsure Account Request form (online): use this form if we have been unable to verify your identity electronically while trying to create an account. The form requires you to enter your legal signature in writing using a computer mouse or touchpad device. 

Paper forms: If you would prefer to complete and mail us the paper form instead, download a form at one of the links below.

Request an Appeal

Request an Appeal Form (PDF). Information about the appeal process.

Authorized Representative

Authorized Representative Form (MNsure Form YY) (PDF) - Use this form to give permission to someone else to act on your behalf (authorized representative).

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.

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