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Provider Forms

Provider Forms

Can’t find a form on this page? Try the looking in the provider portals. The portals can house several provider forms, including credentialing forms, authorization forms, and other provider network forms. If YOU ARE A NON-CONTRACTED PROVIDER authorizations and claims will not process until you complete the provider forms found on the Non-Contracted Providers page.

AuthorizationsNotificationsMedication ReconciliationClaimsNetwork ManagementMiscellaneous
Form CategoryForm Name & Description 
AuthorizationMedical Services Request Form
Use this form when requesting authorization for medical/surgical services, DME, and out-of-network requests.
4497 (pdf)
AuthorizationInpatient Authorization Request
Use this form when requesting authorization outside of Minnesota, North Dakota, South Dakota, Iowa and Wisconsin.
4494
AuthorizationMedical Pharmacy Request
Use this form when requesting authorization for Medical Pharmacy. Medical Pharmacy generally refers to drugs that are injected or infused by a health care professional in the doctor’s office, infusion center or hospital outpatient.
4493 (pdf)
AuthorizationPrivate Room Authorization Request
Use this form when requesting authorization of a private room in a nursing facility.
4496 (pdf)
AuthorizationManaged Care Referral Request Form
ONLY use this form for Restricted Recipient Program (RRP) members. This form is utilized for RRP members which requires a member's primary care provider to submit a referral for all specialists.
>2298 (doc)
> Web Form
Form CategoryForm Name & Description 
NotificationInpatient Admit & Discharge Notification Form
Used when providing notification of an admission or discharge of an acute care hospitalization.
4492 (pdf)
NotificationNursing Facility (NF) Communication Form and Instructions
Used for notification of admission to a Nursing Facility.
DHS-4461-ENG (pdf)
NotificationSwing Bed Notification Form
Used for notification of admission to a Swing Bed.
4495 (pdf)
NotificationWaiver Recommendation for Action Denial, Termination, or Reduction (DTR) Form
Used for notification of a denial, termination, or reduction of waiver services.
2337 (doc)
NotificationWaiver Recommendation for Action Denial, Termination, or Reduction (DTR) Form InstructionInstructions (pdf)
NotificationHospice Notification Form
4735 (doc)
Form CategoryForm Name & DescriptionForm
Medication ReconciliationGuide to Billing Medication Reconciliation4595 (pdf)
Medication ReconciliationLetter to Home Care Agencies4546 (pdf)
Medication ReconciliationMedication Reconciliation Tool4547 (pdf)
Medication ReconciliationPersonal Health Record4548 (pdf)
Form CategoryForm Name & Description 
ClaimsClaim Reconsideration Form/
Provider Appeals Form
4356 (doc)
ClaimsProvider Adjustment Request Form4357 (doc)
ClaimsAttachment Cover Sheet4349 (doc)
Form CategoryForm Name & DescriptionForm
Network ManagementOwnership and Control Interest Disclosure Statement3333 (pdf)
Network ManagementFacility Location Add/Remove Form2319 (doc)
Network ManagementFacility Change UpdateForm2320 (doc)
Network ManagementProvider Quality Complaint Reporting Form2321 (doc)
Network ManagementProvider Contract Application>3715 (doc)
>Web Form
Network ManagementOrganizational Credentialing Assessment Form4692 (pdf)
Network ManagementElectronic Funds Transfer (EFT)Authorization AgreementWeb Form
Network ManagementElectronic Remittance Advice (ERA) Authorization AgreementWeb Form
Network ManagementEFT-ERA User Guide4412 (pdf)
Network ManagementNon-Contracted Provider Facility Information Form4402 (pdf)
Form CategoryForm Name & DescriptionForm
MiscellaneousSterilization Consent FormConsent Form (pdf)
MiscellaneousSterilization Facts for MenLink (web)
MiscellaneousSterilization Facts for WomenLink (web)
MiscellaneousShingles Vaccine Claim Form4277 (pdf)
MiscellaneousShingles Vaccine Billing Process3995 (pdf)
MiscellaneousRecommendation for Authorization of Home Care ServicesDHS-5841-ENG (pdf)