Forms

Service Authorizations

• Gastric By Pass Checklist Form (PDF 136KB)
• Hennepin Health Referral Form (PDF 75.1KB)
• Initial Eating Disorder (PDF 236kb)
• Medical Service Authorization (PDF 20kb)
• Rule 5 Residential Treatment Service Authorization (DOC 229kb)
• PCA Assessment Request (PDF 260kb)
• Psychological Testing
• Day Treatment Service Authorization
• Chiropractic Information
• CPAP/BIPAP Follow-up
• Day Treatment Partial Hospitalization Form - Adult
• Day Treatment Partial Hospitalization Form - Child
• Behavioral Health Concurrent Review Form - Adult
• Behavioral Health Concurrent Review Form - Child
• Neuropsychological Testing Form - Adult
• Neuropsychological Testing Form - Child

Credentialing Forms

• Minnesota Uniform Credentialing
• Minnesota Uniform Practitioner Change
• Minnesota Uniform Reappointment Application

Case Management Forms

• Collaborative Care Plan
• Collaborative Care Plan Instructions
• Individual Transitions Log
• Transition Log Instructions
• Universal Transfer and Fact Sheet

Targeted Case Management

• Mental Health Targeted Case Management Notification (PDF)

Formulary Forms

• Prescription Drug Prior Authorization and Formulary Exception (PDF 277kb)

Provider Operation Forms

• Claim Adjustment/Reconsideration Request (PDF 51kb)
• Automated Clearinghouse (ACH) Funds Transfer Request
• Fraud, Waste and Abuse Training Attestation Form (PDF 27kb)
• Disclosure of Ownership, Business Transactions & Exclusions Statement for Providers (PDF 65kb)
• Providers Address Change Request (DOC 163kb)
• Provider Contract Request (PDF 23kb)
• Provider Appeal (PDF 63kb)
• Provider Information (PDF 93kb)
• Non-contracted Provider Claim Information (PDF 67kb)
• Availability Electronic Remittance Advice Enrollment (PDF 287kb)
• Substitute Form W-9 (PDF Keyable)
• MHP Denial, Termination, Reduction Recommendation (PDF 41kb)