Referrals are not accepted until you have discussed it with the member.

Provider Contact Information

Check all the appropriate boxes to explain the reasons for this referral:

Need/trigger

Please give details of the need/trigger (type of referral)

By clicking 'Submit', this referral will be sent via secured email. However, if you would prefer to print the PDF and fax manually, you can click 'View/Print PDF', print and fax to (612) 336-1370. All required fields must be entered prior to Viewing/Printing.