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.
If you are having difficulty opening a form, click on FORMS HELP.

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 doctor’s 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

Behavioral Health Notification & Authorization (applies to multiple services)

Form Name & Description Form
Initial Behavioral Health Notification
Used to provide notification of IRTS, CMHRTS, Partial Hospitalization, or PRTF services.
4398 (pdf)
Behavioral Health Authorization
Use this form when requesting prior authorization for behavioral health services that exceed threshold. IE: Adult Day Treatment, ARMHS, PHP, IOP, etc.
4381 (pdf)
Psychological Testing Authorization
Use this form to request Neuropsychological Testing or Psychological Testing after threshold is met.
4395 (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)
MH-TCM
Form Name & Description Form
MH-TCM Notification Form
Used when requesting MH-TCM services.
4532 (pdf)
MH-TCM Adult Diagnostic Verification Form DHS-6069A-ENG (pdf) download only
MH-TCM Child/Adolescent Diagnostic Verification Form DHS-6069B-ENG (pdf)
MH-TCM Notification of Denial or Termination
Use this form when a member is receiving MH-TCM services and services will be terminated or determined ineligible at time of request for MH-TCM services.
4533 (pdf)

CTSS

Form Name & Description Form
Children’s Therapeutic Services and Supports (CTSS) Authorization
Used when requesting prior authorization for a CTSS services (crisis assistance, family therapy, group therapy, multi-family group, therapy) after threshold is met.
4390 (pdf)

EIDBI

Form Name & Description Form
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)
DBT

Form Name & Description Form
Dialectic Behavior Therapy (DBT) Authorization
Used when requesting prior authorization for individual DBT therapy or group DBT skills training, or continued therapy.
4498 (pdf)
Behavioral Health Home

Form Name & Description Form
Notification of Eligibility for Behavioral Health Home (BHH) Services DHS-4797-ENG (pdf)
Behavioral Health Home and Managed Care Roles and Responsibilities 5387 (pdf)

Substance Use Disorder
Form Name & Description Form
SUD Residential Admission & Discharge Notification
Used for inpatient substance use disorder treatment within the surrounding 5 state area (MN, IA, WI, ND, SD).
4505 (pdf)
Out of Network SUD Authorization
Used for outpatient (H2035) substance use disorder treatment for providers that are outside of the state of Minnesota. Also used for inpatient (H2036) substance use disorder treatment providers outside the 5 state area (MN, IA, WI, ND, SD).
5991 (pdf)
Healthy Pathways

Healthy Pathways is a program to assist members in preventing mental health deterioration through early intervention and education. This program can also be used as a transition service for those requiring a maintenance level of service or for members who qualify for MH-TCM but opt to use an alternative service instead. Please utilize the following forms to request this service.

Form Name & Description Form
Healthy Pathways Initial Request Form
To be submitted by eligible case manager to initiate, change, renew, or end the service
6021 (pdf)
Healthy Pathways Renewal Request or End of Service Notification Form
To be submitted by eligible case manager to renew or end the service.
6023 (pdf)
Healthy Pathways Program Criteria & Process 5228 (pdf)
Healthy Pathways Provider Billing Process 5227 (pdf)

Diagnostic Assessment Resources
Form Name & Description Form
Diagnostic Assessment (DA) Report Components DA Report Components (external website)
Standard Diagnostic Assessment (DA) Tool Standard Diagnostic Assessment (DA) Tool (doc)

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
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:

  • You are new to South Country, this is your first-time billing South Country, and do not want to become a contracted Provider with South Country at this time
  • You have completed a contracted application to become a South Country Provider and your application is still pending
  • You are reporting a change or updating your file with South Country as it may have changed since you last completed this form (Please note - if you are updating your address only, please complete the Non-contracted Provider Address Change Form below.)

4402 (pdf)
W-9

  • When submitting an Employer Identification Number (EIN) the name must be entered in Box 1 the same as it was registered with the IRS when the EIN was assigned
  • When submitting a Social Security Number (SSN), only the name of the person assigned to that SSN should be Box 1 with the last name, first name and middle initial
  • Only an EIN or SSN can be listed in Part 1, you cannot list both
W-9 (pdf)
NPI/UMPI Notification Form

  • The Social Security Number is required by the State of Minnesota for reporting purposes only
  • If your claim requires a referring or ordering provider, please verify that the provider is eligible to refer or order
  • If the services are Medicare-covered, the referring/ordering provider needs to be enrolled with the Centers for Medicare & Medicaid Services (CMS) or have opted out of enrollment with CMS. (If the provider has opted out, include the affidavit with the claim)
  • If the services are covered by Minnesota Medical Assistance (Medicaid), the referring/ordering provider information will be added to the Minnesota Health Care Programs (MHCP) provider database.
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)

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