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  • Mnsure Form Yy: Authorized Representative Form

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Giving Permission for Someone to Act on My Behalf Someone with permission to act on your behalf is called an authorized representative. This person will have the same responsibilities as you regarding.

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MNsure Application for Health Coverage and Help Paying Costs (DHS-6696) Applicants may use the paper version of the MNsure online application. Applicants submit DHS-6696 to their county or tribal servicing agency. It is available in English, Hmong, Russian, Somali, Spanish and Vietnamese.

Request an application by calling MinnesotaCare at (651) 297-3862 (Twin Cities Metro) or 1-800-657-3672 (toll-free). For TTY call 711 or 1-800-627-3529. Complete it and mail it in. Print the application from the Minnesota Department of Human Services website, complete it and mail it in.

Medical Assistance (MA) is Minnesota's Medicaid program for people with low income. MA does not require you to pay a monthly premium. MA members have small co-pays for some services, usually $1 - $3. MinnesotaCare is a program for Minnesotans with low incomes who do not have access to affordable health care coverage.

Call the health plan customer service number on the back of your health plan ID card or use the provider directory your health plan mailed to you. If you have questions, call Health Care Consumer Support 651-297-3862 or 800-657-3672.

(Failure to complete this form in its entirety will invalidate this authorization) An Authorized Representative is a person you authorize to act on your behalf, in pursuing a claim or an appeal of a denied claim.

You will need to complete an application to determine your actual eligibility. People in householdMedical Assistance for adults over age 18. Monthly / annual income no more thanMinnesotaCare. Annual income no more than1$1,615 / $19,391$29,1602$2,185 / $26,227$39,4403$2,755 / $33,063$49,7204$3,325 / $39,900$60,0005 more rows

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232