Request for an MHCP Member's Claims Payment History

Submit this form to request a history of claims paid for an MHCP member's health care. Use one form per MHCP member.

Email any questions about this form to DHS at DHS.SRUfax@state.mn.us.

MHCP Member Information

FIRST NAME

MIDDLE NAME

LAST NAME

DATE OF BIRTH

MEMBER ID NUMBER (PMI)

Requester's Information

REQUESTED BY:

County worker

Other

FIRST NAME

LAST NAME

PHONE NUMBER

EMAIL ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

I certify that I am entitled to this information under state and federal data privacy laws and I am requesting the information solely for the purpose of administering the Medical Assistance program.

ELECTRONIC SIGNATURE