Complete this form when requesting services for Hennepin Health members, attach relevant clinical documentation, print using the 'View/Print PDF' button at the bottom of the form, and fax to 612-677-6222.

Note: all DME and home care services, including home infusion, require signed order from provider (MD, APRN, PA or CNS).

Incomplete forms may result in denial of requested services for lack of information.

The following turnaround times apply to this request:
Retro Requests: 30 calendar days    Current/Standard Requests: 10 business days    Urgent Requests: 72 hours

Questions? Call Hennepin Health Provider Services at 612-596-1036, press option 2.

Provider Representative Contact Information

Member Information

Requesting/Ordering Practitioner Information

Servicing Provider Information

Coding/Service Information

All required fields must be entered prior to clicking on 'View/Print PDF' to create a PDF.  The PDF may automatically download depending on your browser's settings.

Please fax the printed form to: 612-677-6222