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Form 8288-B Minnesota Hennepin: What You Should Know

Informing health education  A | Part B — Part A premiums and Medicare deductibles, co-insurance and co-pays For more details, see below: You will apply through the Minnesota Health System. You will fill out your application form and provide a self-certified, notarized statement that you have a health care payment agreement with the  Minnesota Department of Health, Minnesota Dental Association, and Health Maintenance Organization for Hennepin County (HMO). You will be approved if: You are a resident of Hennepin County and have a health care payment agreement (HPA) with one of the Health System's insurance companies. If you are not a resident of Hennepin County, fill out the application and mail the completed form  and signed statement to: Minnesota Health System 5200 Nicollet Mall St. Paul, MN 55 Part B — Form 2501 with your payment agreement (see below for more details). You do not need to submit either Form 2501 or your payment agreement as part of your application. You will not be notified that you and  your payment agreement with the State of Minnesota HMO have been approved. The State of Minnesota HMO will be notified. You will receive letter from the state indicating  your HPA with the State of Minnesota HMO's approval.  If you are a non-resident of Hennepin County and your HPA with the State of Minnesota HMO is not  in the approved list when you apply, apply elsewhere. If you are a resident of Hennepin County and you are  not a non-resident of Hennepin County,  you must apply to  the Minnesota Department of Health for a waiver of Part A. Form 2501 must be on record on your person when you come into and stay at HMO's. You will be sent Form 2501 (part). This form can be filled out by paper. If you are a non-resident of Hennepin County and want to apply for Part B of  Form 2501,  you can apply for a waiver of Part B in your application.

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