Service authorization request

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

Request date

Name of person completing form

Direct dial phone number

Extension

Fax number

Member Information

Member name

Date of birth

PMI / MA number

Phone number

ICD-10 diagnosis codes & descriptions

Reason for request

Requesting/Ordering Practitioner Information

Requesting/ordering provider

Phone number

Clinic name

Clinic phone number

Clinic address, including Suite #

City

State

ZIP Code

Requesting/ordering practictioner NPI number

Servicing Provider Information

Servicing clinic/agency/facility

Phone number

Address, including Suite #

City

State

ZIP Code

NPI number

Place of service type/code

Coding/Service Information

CPT/HCPC

Start date

End date

Dollar amount

Number of Units

Comments

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