Hennepin Healthcare and Northpoint Health & Wellness providers only: Complete this form when referring Hennepin Health members to out-of-network specialists, attach relevant clinical documentation, print using the 'View/Print PDF' button at the bottom of the page, and fax to 612-677-6222.

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

The following turnaround times apply to this request: 

Retro Requests: 30 calendar days         Current/Standard Requests: 10 business days      Urgent Requests: 72 hours

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

Provider Representative Contact Information

Member Information

Requesting/Ordering Practitioner Information

Servicing Provider Information

Coding/Service Information

*If dates of service are not specified, Hennepin Health will authorize office visits with the out of network provider for one year from the date of this request. This will apply to office visits 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: 612-677-6222