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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