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


Attach documentation to support medical necessity for inpatient stay.

Type of Admission Information

Provider Information

Facility Information

Partial Hospital Program Admissions Only

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: 612-288-2878