Provider Forms

Forms for Providers

Listed here are forms that should be helpful to providers

• Bariatric Surgery Pre-Authorization Request Form
• CMS-1450 Institutional Claims Guide
• CMS-1500 Professional Claims Guide
• Chiropractic Treatment Request Form
• Early Intensive Behavioral Intervention (EIBI) Services Request Form
• EPNI Provider Automatic Payment
• HIPAA Compliance Act
• Home Health Care Request Form
• ICD-10 Collaborative Webinar
• Immunoglobulin Therapy Pre-Authorization Request Form
• Ind Pract Prov Add Term
• Infliximab Pre-Authorization Request Form
• Inpatient Admission Notification & Pre-Certification Request Form
• MN Uniform Prescription Drug Prior Authorization (PA) Requests & Formulary Exceptions
• Outpatient Physical, Occupational & Speech Therapy Request Form
• Percutaneous Facet Joint Denervation Pre-Authorization Request Form
• Pre-Authorization Request Form
• Provider Appeal Non-MN
• Provider Clinic Location Closure
• Provider Contract Request
• Provider Demographic Change
• Provider Inquiry
• Provider Nonpar Setup Request
• Provider Tin Change
• Psychological & Neuropsychological Testing Pre-Authorization Request Form
• Quantity Limits Form
• Reduction Mammoplasty Pre-Authorization Request Form
• Routine Care Related to Clinical Trials Pre-Authorization/Prior Approval Request Form
• Sample Waiver General
• Specialty Medication Prescription
• Spinal Fusion: Lumbar Pre-Authorization (PA) Request Form
• Step Therapy Form
• Substance Use Disorder Concurrent Review Request Form
• Substance Use Disorder Treatment Initial Request Form
• Transplant Request Form