2022 Transmittal for Substitute Form Approval 

Date Sent:                    Provider ID:  
  Contact Name: 
                                            Email forms and transmittal for approval to: 
  Contact Phone: 
                                            Efile.FormApproval@state.mn.us 
Name of Company: 
                                            Note: You must resubmit your substitute 
  Product Name:                             forms and voucher until they are approved.
           FEIN: 
           ETIN: 
           Fax: 
  Email Address: 

  Check One:      Original         Resubmit 

                           Appoved 
  Minnesota Forms          Yes No            Comments