Intensive Residential Treatment Services (IRTS) beyond 90 days service authorization form

Complete this form when requesting an extension of IRTS services for Hennepin Health members beyond the initial 90 days. Include with this form:

  • Progress notes from the past 7 days
  • An updated treatment plan
  • An updated functional assessment
  • An updated diagnostic assessment

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

The following timelines apply to this request:

  • Retro requests: 30 calendar days    
  • Current/standard requests: 10 business days 
  • Urgent requests: 72 hours


Upon completion, print the form using the “View/print PDF” button and fax it to (612) 677-6222.

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

Provider contact information

Member information

Facility information

Complete the following questions

Coding information *

HCPC code

Number of days requested

Start date

End date