Complete this form to request a substitute health care service. Requests submitted with incomplete data may be denied for lack of information.

  • Print the form by clicking the View/Print PDF button at the bottom.
  • Include the form with relevant clinical documentation and fax to 612-677-6222.

Note: all DME requests require a signed order from the provider (MD, APRN, PA or CNS).

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

Member information

Provider information