Forms/documents

Member materials 

• PMAP/MinnesotaCare provider directory - effective 2/1/2023 (PDF)
• SNBC provider directory - effective 2/1/2023 (PDF) 

• List of covered drugs (Formulary) - effective 3/1/2023 (PDF)
• List of covered drugs for SNBC members with Medicare coverage - effective 4/1/2022 (PDF)

• Prior authorization chart (PDF)

• 2023 PMAP member handbook (PDF)
• 2023 MinnesotaCare member handbook (PDF)
• 2023 SNBC member handbook (PDF) 

Forms

• 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

• Adolescent immunization:  English (PDF) 
• Annual dental visit:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Cervical cancer screening:  English (PDF)  Somali (PDF)  Spanish (PDF) 
• Child & Teen Checkup visits: 0-30 months:  English (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)

Advance health care directive (ages 18+)

You can inform others of your health care wishes with an advance health care directive. A health care directive is a written document that informs others of your wishes about your health care. It allows you to name a person to decide for you if you are unable to or if you want someone else to decide for you. 

You don’t need to have a health care directive. But writing one helps to make sure your wishes are followed. You must be at least 18 years old to make a health care directive. 

For more information, visit these websites:

• Minnesota Department of Health – Advance Care Planning
• University of Minnesota – Health Care Directive Planning Toolkit

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: English (PDF)  Hmong (PDF)  Somali (PDF) Spanish (PDF)
• Rights and safety with third-party health information apps
• Limited English Proficiency (LEP) plan (PDF) 

DHS approved: 9/24/2020, HC-1110-MC; 2/27/23, QM-1417-MC