Complete this form for Hennepin Health members, attach relevant clinical documentation, print using the gray "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