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Forms for providers
Commonly used forms for doing business with HealthPartners
Claims
- Sign in to check the status of your claim adjustment and appeal requests. Select Claim Adjustments and Appeals from your menu.
- Claim Adjustment Requests - online
Add new data or change originally submitted data on a claim - Claim Appeal Requests - online
Reconsideration of originally submitted claim data - Claim Attachment Submissions - online
- Claim Correspondence - online
Contracting, Credentialing and Enrollment
Forms for submitting prior authorization requests
Fillable forms work best when using the Adobe Acrobat Reader DC application. Visit get.Adobe.com/reader for more information.
Sign in to check the status of your prior authorization request and select Authorizations and referrals from your menu.
- Airway Clearance System/Chest Compression Generator System review
- CPM review
- DHS Nursing Facility (NF) Communication Form DHS-4461
- Durable Medical Equipment (DME) review
- Enteral Nutrition (Formula) review
- Enteral Nutrition (Formula) review - Minnesota Health Care Programs
- Fixed Wing Air Ambulance Transportation review
- Genetic Testing review
- Home Health Care review
- Hospital Bed review
- For In-network Benefit Reviews please refer to the updated policy: Network Adequacy Exception Request – Benefit Review
- Lift Chair review
- Medical-Dental Procedures - Accidental Dental review
- Medical-Dental Procedures - Facility-General Anesthesia review
- Medical-Dental Procedures - Oral Surgery for Dental Conditions review
- Medical-Dental Procedures - Orthognathic Surgery review
- Medical-Dental Procedures - Surgical Intervention for TMD review
- Medical gender services/surgery review
- Mental Health Partial Hospitalization review
- Mental Health Residential Treatment Services review
- PCA Assessment review
- PCA Change of Vendor review
- Pneumatic Compression Devices review
- Procedures review
- Radiofrequency Ablation Spine review
- Sacroiliac (SI) injections to treat SI joint pain review
- Site of Service-Attended Polysomnography for Evaluation of OSA review
- Skilled Nursing Facility Admission review
- Skilled Nursing Facility Continued Stay review
- Specialty Mattress Gp I or Gp II review
- Spinal Cord Stimulator review
- Spinal Fusion-Lumbar review
- Synagis (RSV) Season review
- Substance Use Disorder Services review
- Transcranial Magnetic Stimulation review
- Transplant Prior Notification review
- UnityPoint In-Network review
- Upper airway, hypoglossal nerve stimulation therapy for obstructive sleep apnea review
- Varicose vein procedures of the lower extremities review
- Weight Loss Surgery review
- Wheelchair review
Forms for dental services and requests
- Clinic address change form
- Clinic Legal or Marketing name change form
- Initial Dental Credentialing application
- Dental Provider Change Notice
- Dental Procedures - Accidental Dental review
- W-9 form for Tax Id Changes
- Prior Notification of Diabetes or Pregnancy
- Provider Notification for HPCare Add'tl Prophys
Forms for pharmacy services and requests
- Cell and Gene Attestation form - Hemophilia A
- Cell and Gene Attestation form - Hemophilia B
- CMS standard format/CCD creator
- Disease, Case and Lifestyle Management
- Minnesota Uniform Prior Authorization and Formulary Exception
- MTM credentialing application
- New Drug Request
- Prior Authorization / Exception - Fax