MN Restricted Recipient Program (MRRP) Medical Referral

To ensure proper payment, the restricted primary care provider must fax this medical referral form immediately to the Minnesota Restricted Recipient Program at Hennepin Health. Please fax this form to: (612) 677-6222

If you have any questions, please call Hennepin Health's Provider Services: (612) 596-1036, press option 2.

Provider representative contact information

Request date

Name of person completing form

Direct dial phone number

Extension

Fax number

MRRP member information

Member name

PMI number

Date of birth

Primary restricted provider

Primary restricted provider

Provider NPI number

Phone number

Street address

City

State

ZIP code

Referral Information

Referring to

Specialty

Clinic name

Clinic NPI number

Phone number

Street address

City

State

ZIP code

Reason for referral

ICD-10 diagnosis codes and descriptions

Coding/Service Information

CPT/HCPC

Start date

End date

Restricted primary provider signature

Signed date