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Provider Forms

Provider Forms

Can’t find a form on this page? Try the looking in the provider portal. The portal has 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 ManagementNon-Contracted ProvidersTransportationMiscellaneous
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)
NotificationCritical Access Hospital Swing Bed Notification Form
Used for notification of admission to a Swing Bed.
4495 (pdf)
NotificationDSD and CADI Only Waiver Recommendation for Action Denial, Termination, or Reduction (DTR) Form
Used for notification of a denial, termination, or reduction of DSD or CADI waiver services.
5208 (pdf)
NotificationHospice Notification Worksheet
4735 (doc)
Form CategoryForm Name & DescriptionForm
Medication ReconciliationGuide to Billing Medication Reconciliation4545 (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 (pdf)
ClaimsAttachment Cover Sheet4349 (doc)
ClaimsClaims Error Codes & Descriptions
Troubleshooting help
5126 (pdf)
Form CategoryForm Name & DescriptionForm
Network ManagementOwnership and Control Interest Disclosure Statement3333 (pdf)
Network ManagementContracted Entity Location Add/Remove Form5079 (doc)
Network ManagementContracted Entity Change UpdateForm5073 (doc)
Network ManagementProvider Assurance Statement for Telemedicine
Only for eligible providers who meet the MHCP definition to provide Telemedicine Services.
5206 (pdf)
Network ManagementProvider Quality Complaint Reporting Form2321 (doc)
Network ManagementProvider Contract Application>5078 (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 Form4402v6 (pdf)
Network ManagementNon-Contracted Provider Address Change Form4911 (pdf)
Form Name 
Non-Contracted Provider Facility Information Form 4402 (pdf)
Non-Contracted Provider Address Change Form

This form is for non-contracted providers only!
4911 (pdf)
NPI Notification Form4630 (doc)
W-9W-9 (pdf)
Electronic Funds Transfer (EFT)Authorization AgreementWeb Form
Electronic Remittance Advice (ERA) Authorization AgreementWeb Form
EFT-ERA User Guide4412 (pdf)
Waiver of Liability Form4629 (doc)
Provider Assurance Statement for Telemedicine
Only for eligible providers who meet the MHCP definition to provide Telemedicine Services.
5206 (pdf)
Form CategoryForm Name & DescriptionForm
TransportationMinor Parental Authorization Consent Form
This form must be used when transporting any minor younger than 18 years of age without an accompanying parent or guardian.
Consent Form (pdf)
TransportationRideConnect Brochure for Health Care Providers
A brochure for health care providers and caregivers describing the RideConnect service.
RideConnect Brochure (pdf)
TransportationRideConnect Request Form
The form used by providers and caregivers to request non-emergency medical transportation for patients from the RideConnect service.
Web Form
TransportationProvider Manual Chapter 27Provider Manual
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)
MiscellaneousPCA Request Form5207 (pdf)