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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
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
W9 for contracted providers (PDF)
Download
W-9 for non-contracted providers (PDF)
Download
Contracting and credentialing
Contracted provider information form (PDF)
Download
Disclosure of ownership changes form (PDF)
Download
Facility credentialing application (PDF)
Download
Location add/term/change form (PDF)
Download
Location and practitioner template roster (XLS)
Download
Network contract request form (PDF)
Download
Non-contracted provider information form (PDF)
Download
Practitioner initial credentialing application (PDF)
Download
Practitioner re-credentialing application (PDF)
Download
Practitioner add/term/change form (PDF)
Download
Quarterly complaint form (DOCX)
Download
Site visit checklist (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