Substitute health service request

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

Member name

Date of birth

PMI/MA identification number

Member phone number

ICD-10 diagnosis code and description

Reason for request

Provider information

Name of person completing form

Direct dial phone number

Ext.

Provider

Provider phone number

Provider fax number

NPI number

Address

City

State

Zip code

Additional information

Substitute service requested: This must be a service or item outside of the benefit set.

Covered service or item that is being substituted: This must be a covered benefit.

Cost-effectiveness: List why the requested substitute service is more cost effective (costs less) than the covered service. Be as specific as possible.

Benefit to the health, quality of life and safety for the member: List why the substitute service increases the health, quality of life and safety for the member.

Proposed date(s) of service