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Forms
Below are forms for providers. Fillable forms open the best using Internet Explorer.
Behavioral Health
Client placement authorization (PDF)
Download
Diagnostic assessment (PDF)
Download
Mental health TCM notification form (PDF)
Download
Neuropsych testing service authorization form (DOC)
Download
Psychological testing form (PDF)
Download
Service authorization form for ARHMS, IRTS and ACT services (DOC)
Download
Claims and payment
Automated clearinghouse ACH funds transfer request (DOC)
Download
Claims adjustment reconsideration request (PDF)
Download
Client placement authorization (PDF)
Download
Provider appeal form (PDF)
Download
Provider information form for contracted providers (PDF)
Download
Provider information form for non-contracted providers (PDF)
Download
W9 for contracted providers (PDF)
Download
W-9 for non-contracted providers (PDF)
Download
Contracting and credentialing
Location add change form (PDF)
Download
Become a contracted provider form (PDF)
Download
Disclosure of ownership changes form (PDF)
Download
Location and practitioner roster template (XLS)
Download
MN uniform credentialing application - initial (PDF)
Download
MN uniform credentialing application - reappointment (PDF)
Download
MN uniform practitioner change form (PDF)
Download
Organizational credentialing application (PDF)
Download
Provider demographic change form (PDF)
Download
Provider information form for contracted providers (PDF)
Download
Quarterly complaint form (DOCX)
Download
W9 for contracted providers (PDF)
Download
PCA / home care
MA home care technical change request (PDF)
Download
PCA services referral form (PDF)
Download
PCA technical change request (PDF)
Download
Pharmacy
Drug reconsideration request (PDF)
Download
Prescription drug prior authorization form (PDF)
Download
Release of information
Patient authorization for release of information form (PDF)
Download
Restricted recipient
Medical referral for Minnesota restricted recipient program enrollee (PDF)
Download
Service authorizations
Continuity of care form (PDF)
Download
Hennepin Health Partnered Provider Out-Of-Network Referral Form (PDF)
Download
Inpatient services notification authorization request form (PDF)
Download
Neuropsych testing service authorization form (DOC)
Download
Psychological testing form (PDF)
Download
Service authorization request form (PDF)
Download
Service authorization request form for ARHMS, IRTS and ACT services (DOC)
Download
Substitute health service request form (PDF)
Download
Provider updates
Provider updates