Healthy Minnesota Contribution Program Application
(Minnesota Care receipients only)
Summary of Benefits
Application Form for the Healthy Minnesota Contribution Program (updated 7/9/12)
Deductible Plan Application
Summary of Benefits
Application Form for MCHA Deductible Plans
Medicare Supplement Plans
Summary of Benefits for the Basic Medicare Supplement Plan (updated 6/27/12)
Medicare Application form for the Basic Medicare Supplement Plan (updated 7/9/12)
Miscellaneous Forms
MCHA Cancellation Form
Automatic Premium Payment Option
MCHA Plan Change Request Form
Enrollee Address Change and Dependent Additions Form
MCHA Change to a Standard (non-tobacco) Premium Rate Request Form
Authorization to Disclose Protected Health Information to a Designated Representative Form
Request for Copy of Protected Health Information Form
Healthy Minnesota Contribution Program Request to Backdate Coverage Form
