Complete this form for Hennepin Health members, attach relevant clinical documentation, print using the 'View/Print PDF' button at the bottom of the form, and fax to 612-288-2878.
Incomplete forms may result in denial of requested services for lack of information.
Questions? Call Hennepin Health Provider Services at 612-596-1036, press option #2.
Member Information
Documentation
Attach documentation to support medical necessity for inpatient stay.
Type of Admission Information
Provider Information
Facility Information
Partial Hospital Program Admissions Only
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Please fax the printed form to: 612-288-2878