Forms and documents

Member materials 

• PMAP/MNCare provider directory - effective 10/1/2021 (PDF)
• SNBC provider directory - effective 10/1/2021 (PDF) 

• List of covered drugs (Formulary) - effective 10/1/2021 (PDF)
• List of covered drugs for SNBC members with Medicare coverage - effective 9/1/2021 (PDF)

• Prior authorization chart (DOCX)

• 2021 PMAP member handbook (PDF)
• 2021 MNCare member handbook (PDF)
• 2021 SNBC member handbook (PDF) 

Forms

• Advance directive form (PDF) 

• Member information release form (PDF)

• Member appeal and complaints (grievances) form (PDF)

• Request for protected health information form (PDF) 

• Change to protected health information form (PDF)

• Request for personal health information disclosures form (PDF) 

Rewards vouchers

• Annual dental visit:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Cervical cancer screening:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Child & Teen Checkup visits: 0-14 months:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Child & Teen Checkup annual visit: 15 months – 21 years:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Diabetic blood glucose test - A1C:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Diabetic eye exam:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Mammogram screening:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Postpartum visit:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• 1st prenatal visit:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• 9 prenatal visits:  English (PDF)  Somali (PDF)  Spanish (PDF) 

• Car seat program FAQ (PDF)

Notices

Members have a Bill of Rights pursuant to Minnesota Statutes, Section 62D.07, subdivision 3. You can read your Bill of Rights in your member handbook.

• Nondiscrimination notice
• Notice of privacy practices (PDF)
• Language and civil rights notices (PDF)
• Rights and safety with third-party health information apps
• Limited English Proficiency (LEP) plan (PDF) 

DHS approved 9/24/2020 ID# HC-1110-MC