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Forms/documents

Member materials 

  • PMAP/MNCare provider directory - effective 4/1/2022 (PDF)
  • SNBC provider directory - effective 4/1/2022 (PDF) 
  • List of covered drugs (Formulary) - effective 3/1/2022 (PDF)
  • List of covered drugs for SNBC members with Medicare coverage - effective 4/1/2022 (PDF)
  • Prior authorization chart (PDF)
  • 2022 PMAP member handbook (PDF)
  • 2022 MNCare member handbook (PDF)
  • 2022 SNBC member handbook (PDF) 

Forms

  • Advance health care 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


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612-596-1036, TTY 800-627-3529

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