Header
Separator
Eligibility Question
Patient Information
Provider Information
Requested Therapy
Administering Facility Information
Separator
Please attach any supporting documentation
Submit

Prior Authorization / Exception

For questions, please call 952-883-5813 or 800-492-7259. Incomplete submissions will be returned and may delay review.

Will waiting the standard review time seriously jeopardize the life or health of the member's ability to regain maximum function?

Yes

Patient Information

First name

Last name

Date of Birth

HealthPartners Member Number

Street Address 1

Street Address 2

City

State

Zip Code

Weight

Provider Information

currentDateTimeStamp

Provider First Name

Provider Last Name

Clinic Name

Street Address 1

Street Address 2

City

State

Zip Code

Specialty

Telephone Number

Provider NPI

Fax Number

Contact Person

Recommended by a consultant?

Yes

Consultant Name

Consultant Specialty

Requested Therapy

If injectable medication, how is it being administered?

Self-administered

Professionally-administered

Requested Drug name

Requested Drug dosing schedule

HCPC Code

Date therapy initiated

Requested Start Date

Duration

Is the brand name medically necessary?

Yes

Other duration

ICD-10 Diagnoses (Primary first)

Previous therapies and outcomes / Prescribing Rationale

Administering Facility Information

Administering Facility Name

Street Address 1

Street Address 2

City

State

Zip Code

Federal Tax ID

NPI

Facility Type

Please attach any supporting documentation

HealthPartners Preferred Drug List (Formulary), Prior Approval, and Medical Coverage Criteria are available at www.healthpartners.com

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