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

MRRP member information

Primary restricted provider

Referral Information

Coding/Service Information