Canโt 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.
If you are having difficulty opening a form, click on FORMS HELP.
- Authorizations
- Notifications
- Behavioral Health
- Medication Reconciliation
- Claims
- Non-Contracted Providers
- Contracted Providers
- Transportation Forms
- Miscellaneous
Authorizations
Form Name & Description | Form |
---|---|
Medical Services Request Form Use this form when requesting authorization for medical/surgical services, DME, and out-of-network requests. |
4497 (pdf) |
Early Intensive Developmental and Behavior Intervention (EIDBI) Authorization Used to request authorization for EIDBI services. The form can also be used to request prior authorization for EIDBI services after the threshold has been met. |
4894 (pdf) |
Inpatient Authorization Request Use this form when requesting authorization outside of Minnesota, North Dakota, South Dakota, Iowa and Wisconsin. |
4494 (pdf) |
Medical 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 doctorโs office, infusion center or hospital outpatient. |
4493 (pdf) |
Private Room Authorization Request Use this form when requesting authorization of a private room in a nursing facility. |
4496 (pdf) |
Managed 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. |
>6226 (pdf) >Web Form |
Notifications
Form Name & Description | Form |
---|---|
Inpatient Admission & Discharge Notification Used when providing notification of an admission or discharge of an acute care hospitalization. |
4492 (pdf) |
Behavioral Health Hospitalization Inpatient Admission & Discharge Notification Providers within the 5-state area (MN, ND, SD, WI, IA) use this notification form for a behavioral health admission and discharge from a psychiatric facility or mental/behavioral health unit. |
5116 (pdf) |
Nursing Facility (NF) Communication Form and Instructions Used for notification of admission to a Nursing Facility. |
DHS-4461-ENG (pdf) download only |
Critical Access Hospital Swing Bed Notification Form Used for notification of admission to a Swing Bed. |
4495 (pdf) |
DSD Waiver Only Recommendation for Action Denial, Termination, or Reduction (DTR) Used for notification of a denial, termination, or reduction of DSD waiver services. |
6150 (pdf) |
Hospice Notification Form |
4735 (pdf) |
Behavioral Health
Choose the form type below
Medication Reconciliation
Form Name & Description | Form |
---|---|
Guide to Billing Medication Reconciliation | 4595 (pdf) |
Medication Reconciliation Tool | 4547 (pdf) |
Personal Health Record | 4548 (pdf) |
Claims
Form Name & Description | Form |
---|---|
Claim Reconsideration Form/ Provider Appeals Form -------Important Update!------- We are transitioning to an electronic claim appeal submission. Starting April 1, 2023, this Word form will no longer be available. You will be required to submit your claim appeal electronically on our Provider Portal by selecting โForms & Resourcesโ then โProvider Appeal Form.โ Call the Provider Contact Center at 1-888-633-4055 with any questions. |
4356 (doc) |
Provider Adjustment Request Form | 4357 (pdf) |
Attachment Cover Sheet | 4349 (doc) |
Claims Error Codes & Descriptions Troubleshooting help |
5584 (pdf) |
Non-Contracted Providers
Form Name | |
---|---|
REQUIRED NON-CONTRACTED FORMS TO ALLOW CLAIMS ADJUDICATION ARE: | |
Non-Contracted Provider Facility Information Form For Non-Contracted Providers only. Please complete this form if:
|
4402 (pdf) |
W-9
|
W-9 (pdf) |
NPI/UMPI Notification Form
|
5071 (pdf) |
ADDITIONAL FORMS/GUIDES | |
Electronic Funds Transfer (EFT) Authorization Agreement | Web Form (external link) |
Electronic Remittance Advice (ERA) Authorization Agreement | Web Form (external link) |
EFT-ERA User Guide Also refer to Provider Manual Chapter 4, Provider Billing |
4412 (pdf) |
Provider Assurance Statement for Telehealth Only for eligible providers who meet the MHCP definition to provide Telehealth Services. |
5206 (pdf) |
Non-Contracted Provider Address Change Form This form is for non-contracted provider address changes only! |
4911 (pdf) |
Waiver of Liability Form Must be sent with claim reconsideration/appeal |
4629 (doc) |
Provider Contract Application | 5078 (pdf) Web Form (external link) |
Contracted Providers
Form Name & Description | Form |
---|---|
Ownership and Control Interest Disclosure Statement | 3333 (pdf) |
Contracted Entity Location Add/Remove Form | 5079 (doc) |
Contracted Entity Change Update Form | 5073 (doc) |
Provider Assurance Statement for Telehealth Only for eligible providers who meet the MHCP definition to provide Telehealth Services. |
5206 (pdf) |
Provider Quality Complaint Reporting Form | 4458 (doc) |
Organizational Credentialing Assessment Form | 4692 (pdf) |
Electronic Funds Transfer (EFT)Authorization Agreement | Web Form |
Electronic Remittance Advice (ERA) Authorization Agreement | Web Form |
EFT-ERA User Guide | 4412 (pdf) |
Transportation Forms
Form Name & Description | Form |
---|---|
Minor 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) |
RideConnect Brochure for Health Care Providers A brochure for health care providers and caregivers describing the RideConnect service. |
RideConnect Brochure (pdf) |
RideConnect Request Form The form used by providers and caregivers to request non-emergency medical transportation for patients from the RideConnect service. |
Web Form |
Provider Manual Chapter 27 | Provider Manual |
Miscellaneous
Form Name & Description | Form |
---|---|
Sterilization Consent Form | Consent Form (pdf) |
Sterilization Facts for Men | Link (web) |
Sterilization Facts for Women | Link (web) |
Shingles Vaccine Claim Form | 5546 (pdf) |
Shingles Vaccine Billing Process | 5545 (pdf) |
Recommendation for Authorization of Home Care Services | DHS-5841-ENG (both web and printable) download only |
PCA Request Form | 5207 (pdf) |