DHS-4740-ENG 1-17
Minnesota Family Planning Program
Application
(Part of Minnesota Health Care Programs)
What is this application for?
Use this application to apply for the Minnesota Family Planning Program (MFPP). MFPP covers
only family planning services and supplies for men and women who are not enrolled in Medical
Assistance (MA).
Fill out page 1 and sign the application on page 5 to apply only for short-term coverage with MFPP.
Fill out the entire application to apply for ongoing coverage with MFPP.
Can I get coverage right away?
Some clinics use this application to see whether you can get short-term coverage. Short-term
coverage begins right away and lasts for up to two months.
For a list of clinics that can give short-term coverage, call MFPP at the numbers below.
What do I need to do with this form?
Read the Notice of Privacy Practices and Notice of Rights and Responsibilities at the end of this
application. Tear off these pages and keep them.
Use one application for each person applying.
Answer all questions on pages 1-4. If you are filling out this application by hand, use blue or black
ink. Print clearly.
Sign and date the application on page 5.
Mail or fax the completed application to this address:
Minnesota Department of Human Services
PO Box 64960
St. Paul, MN 55164-0960
Fax: 651-431-7532
How do I apply for health coverage beyond family planning?
You can apply for health coverage and help paying costs in the following ways:
Apply online at www.mnsure.org
Fill out the
Application for Health Coverage and Help Paying Costs (DHS-6696)
(PDF). Find
this application at www.mnsure.org. Or have one mailed to you by calling 651-431-2670 or
800-657-3739.
Questions
If you have questions or need help, call MFPP at 651-431-3480 (Twin Cities metro area) or
888-702-9968 (outside Twin Cities metro area).
DHS-4740-ENG 1-17
Minnesota Family Planning Program
Application
(Part of Minnesota Health Care Programs)
What is this application for?
Use this application to apply for the Minnesota Family Planning Program (MFPP). MFPP covers
only family planning services and supplies for men and women who are not enrolled in Medical
Assistance (MA).
Fill out page 1 and sign the application on page 5 to apply only for short-term coverage with MFPP.
Fill out the entire application to apply for ongoing coverage with MFPP.
Can I get coverage right away?
Some clinics use this application to see whether you can get short-term coverage. Short-term
coverage begins right away and lasts for up to two months.
For a list of clinics that can give short-term coverage, call MFPP at the numbers below.
What do I need to do with this form?
Read the Notice of Privacy Practices and Notice of Rights and Responsibilities at the end of this
application. Tear off these pages and keep them.
Use one application for each person applying.
Answer all questions on pages 1-4. If you are filling out this application by hand, use blue or black
ink. Print clearly.
Sign and date the application on page 5.
Mail or fax the completed application to this address:
Minnesota Department of Human Services
PO Box 64960
St. Paul, MN 55164-0960
Fax: 651-431-7532
How do I apply for health coverage beyond family planning?
You can apply for health coverage and help paying costs in the following ways:
Apply online at www.mnsure.org
Fill out the
Application for Health Coverage and Help Paying Costs (DHS-6696)
(PDF). Find
this application at www.mnsure.org. Or have one mailed to you by calling 651-431-2670 or
800-657-3739.
Questions
If you have questions or need help, call MFPP at 651-431-3480 (Twin Cities metro area) or
888-702-9968 (outside Twin Cities metro area).
651-431-2670 or 800-657-3739
Attention. If you need free help interpreting this document, call the above number.
ያስተውሉ፡ ካለምንም ክፍያ ይህንን ዶኩመንት የሚተረጉምሎ አስተርጓሚ ከፈለጉ ከላይ ወደተጻፈው የስልክ ቁጥር ይደውሉ።
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
သတိ ။ ဤစာရြ က ္ စ ာတမ္ း အားအခမဲ ့ ဘ ာသာျပန္ ေ ပးျခင္ း အကူ အ ညီ လ ု ု ိ အ ပ္ ပ ါက၊ အထက္ ပ ါဖု ု န ္ း နံ ပ ါတ္ က ု ု ိ ေ ခၚဆု ု ိ ပ ါ။
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請注意,如果您需要免費協助傳譯這份文件,請撥打上面的電話號碼。
Attention. Si vous avez besoin d’une aide gratuite pour interpréter le présent document, veuillez appeler au
numéro ci-dessus.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
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알려드립니다. 이 문서에 대한 이해를 돕기 위해 무료로 제공되는 도움을 받으시려면 위의
전화번호로 연락하십시오.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado
arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA1 (9-15)
For accessible formats of this publication or
assistance with additional equal access to human
services, write to DHS.info@state.mn.us, call
800-657-3739, or use your preferred relay service.
Clear Form
*DHS-4740-ENG*
DHS-4740-ENG
1-17
MINNESOTA HEALTH CARE PROGRAMS
Minnesota Family Planning Program Application
Provider Use Only
(If PE is approved, complete the information below and fax pages 1 and 5 to 651-431-7532.)
PROVIDER NAME
PROVIDER ADDRESS
NPI NUMBER
PROVIDER PHONE
DATE PE APPROVED
1.
Tell us about yourself below.
FIRST NAME
MIDDLE INITIAL
LAST NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER*
DAYTIME PHONE NUMBER
GENDER
ARE YOU PREGNANT?
(MM/DD/YYYY)
M
F
Yes
No
HOME STREET ADDRESS
APT. NUMBER
CITY
STATE
ZIP CODE
COUNTY
MAILING ADDRESS (where you would like notices sent, if different from the address above)
APT. NUMBER
CITY
STATE
ZIP CODE
Do you plan to make Minnesota your home?
Check this box if
you are homeless.
Yes
No
EXPLAIN:
SPOKEN LANGUAGE
WRITTEN LANGUAGE
English
Spanish
Other:
English
Spanish
Other:
If you do not speak English well, do you need someone who speaks your language to help you?
Yes
No
Are you Latino or Hispanic?
What is your
White
Asian
American Indian or Alaskan Native
(optional)
race?
(optional)
Yes
No
Black or African American
Pacific Islander or Native Hawaiian
*You do not need to give us your Social Security number if you are applying only for short-term coverage.
2. What is your household and income information?
Complete these questions if you are applying for short-term MFPP coverage.
How many family members live in your household?
(Include yourself, parents, spouse, and children under age 19 who live with you.)
a.
How much is the income for your household?
(Choose one and fill in the amount.) If you are under 21, count only your own income.
b.
Yearly amount $
Monthly amount $
Weekly amount $
1
3.
Do you have a Social Security number (SSN)?
No
Yes
If yes, what is your SSN?
If no, have you applied for an SSN?
Yes
No – choose a reason and write the letter here:
Reasons for not applying for an SSN:
A. Not eligible for an SSN
B. Can be issued for nonwork reason only
C. No SSN because of religious objections
4. Do you live with your spouse?
Yes – fill in below
No
Include a spouse who is living away from home for a short time.
SPOUSE’S FIRST NAME
MI
LAST NAME
If you live with your wife, is she pregnant?
Yes
No
5.
Do you live with your children or stepchildren?
No
Yes – fill in below
Include children who are living away from home for a short time.
a. NUMBER OF CHILDREN UNDER AGE 19 b. NAMES OF CHILDREN UNDER AGE 19
6. What is your tax-filing status?
Provide your tax-filing status. You can still apply for MFPP even if you do not file a federal income tax return.
Do you plan to file a federal income tax return next year?
Yes – answer questions a–c
No – answer question c
a. IF YES, NAME OF SPOUSE
Will you claim any dependents on your tax return?
Yes
No
b.
If yes, list name(s) of dependent(s):
Will you be claimed as a dependent on someone else’s tax return?
Yes
No
c.
If yes, list the name of the tax filer:
How are you related to the tax filer?
7.
Do you, or does anyone you listed in question 4, 5, or 6, work?
No
Yes – fill in below
Note: If you are under age 21, include only your own income.
Subtract pretax deductions for childcare, health insurance, retirement plans, transportation assistance or other nontaxable benefits.
How often paid?
Gross income per
Is this a seasonal
pay period
Date of most
(weekly, every two weeks,
Name
Employer name
or temporary job?
recent paycheck
monthly, other)
(include tips)
Yes
No
$
Yes
No
$
$
Yes
No
$
Yes
No
You must give us proof of this income. Proof can be pay stubs from the last 30 days, a statement from your
employer, or your most recent federal tax return if your income has not changed.
2
8. Are you, or is anyone you listed in question 4, 5, or 6, self-employed?
No
Yes – fill in below.
Note: If you are under age 21, include only your own income.
Name of person
Name of business
Yearly income or loss
$
$
You must give us proof of this income. Proof can be your most recent federal income tax return (including all related
schedules and forms) or your business records if you do not file a tax return.
9.
Do you, or does anyone you listed in question 4, 5, or 6, get money from sources other
than work or self-employment?
Yes – fill in below
No
Note: If you are under age 21, include only your own income.
Do not include child support, workers’ compensation, Supplemental Security Income (SSI) benefits, or veterans’ benefits. Include any
onetime lump-sum income (for example, prizes, awards, gambling winnings); unemployment benefits; pension or other retirement
income; Social Security disability or retirement benefits; alimony received; net rental or royalty income; and interest and dividends.
Date payment last
Name
Type of income
Start date
Amount
How often received
received
$
$
$
$
You must give us proof of this income. Proof can be a statement from the place that sends the income or a direct
deposit statement from your bank from the last 30 days.
10. Do you, or does anyone you listed in question 4, 5, or 6, have income adjustments?
No
Yes – fill in below
If you pay for certain things that can be subtracted from gross income on a federal income tax return, telling us about them could help
you qualify for MFPP. (See the list of allowed income adjustments on Attachment B.)
Type of adjustment
Amount
How often?
$
$
$
You must give us proof of these adjustments. Proof can be your most recent federal income tax return that show
these adjustments or other statements or receipts for these expenses.
11. Is any part of the income you reported in questions 7, 8, and 9 educational funds or
American Indian or Alaska Native income?
Educational funds are scholarships, awards or grants that are used for educational purposes.
American Indian or Alaska Native income is:
per-capita or other payments from a tribe that come from natural resources, usage rights, leases, or royalties; and
payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the
Department of Interior (including reservations and former reservations).
No, none of the income I listed is from these sources
Yes – fill in below
AMOUNT OF EDUCATIONAL FUNDS USED FOR EDUCATIONAL PURPOSES
AMOUNT OF AMERICAN INDIAN OR ALASKA NATIVE INCOME FROM THE SOURCES ABOVE
$
$
3
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