Provider Forms
Latest Provider Updates
Apr. 28, 2010 Primary Care Clinic Accessibility Survey starts May 1st. Read more...
Mar. 30, 2010 $75k available for Rural Health Collaborative Pilot Grants. Download .pdf
Mar. 30, 2010 Mar.-Apr.. issue of Provider Network News. Download .pdf
Jan. 28, 2010 Provider Bulletin on Maternal Depression Screening. Download .pdf
Jan. 28, 2010 Jan.-Feb. issue of Provider Network News. Download .pdf
Nov. 16, 2009 New Provider Incentive for Lead Testing. Read more...
Nov. 4, 2009 Electronic Claim Submission Notice. Download...(.pdf)
Nov. 4, 2009 Chemical Dependency Program Claim Submission update. Download...(.pdf)
Sept. 24, 2009 The September-October edition of "Provider Network News" is hot off the press. Read more...(.pdf)
Aug. 3, 2009 South Country Health Alliance is now part of the Minnesota Credentialing Collaborative (MCC). Read more...(.pdf)
July 23, 2009 The July-August 2009 issue of "Provider Network News" is released (.pdf)
May 27, 2009 Sign up online to receive provider updates and SCHA's monthly provider newsletter "Provider Network News" direct to your email inbox
Mar. 30, 2009 SCHA is providing the following disease management programs for members: heart condition, diabetes, and asthma. Read more on the new Disease Management Programs page.
In alphabetical order:
- Attachment Cover Sheet (.doc)
- Authorization Request Form (.doc) | Medical/Surgical Services, DME, and out-of-network requests
- Certificate of Need - Transportation (.pdf)
- Certification of SED (.doc)
- Certification of SPMI (.doc)
- Claim Reconsideration Form (.doc)
- Claim Recoupment or Adjustment Fax Form (.doc)
- Disclosure Form for Providers (.pdf)
- Elderly Waiver Notification Form (.doc)
- Facility Change Update Form (.doc)
- Government CD Admission Worksheet (.doc) | Used for all Chemical Dependency Treatment, Inpatient and Outpatient
- Government CD Request Worksheet (.doc) | Rule 25 Assessors only
- Government Notification (.doc) | Used for Notification of these services: ACT, ARMHS, CTSS, Crisis Stabilization
- Home Care Workflow Sheet (.pdf)
- Inpatient Notification Worksheet (.doc)
- Managed Care Referral Request Form
online form | .pdf version.
- Mental Health Admission Worksheet (.doc) | Used for both Notification and Authorization of Acute Inpatient Mental Health, IRTS Services and Children's Residential Rule 5 Treatment
- Mental Health Targeted Case Management (MH-TCM) Eligibility Determination Form (.doc)
- MN Uniform Practitioner Change Form (.doc)
- MN Uniform Provider Credentialing Application (.pdf)
- MN Uniform Provider Credentialing Application–Online Form (.doc)
- MN Uniform Provider Reappointment Form (.pdf)
- MN Universal Outpatient Mental Health/Chemical Health Authorization Form (.pdf) | Used for authorizing AMRHA, CTSS, Crisis Stabilization, Individual/Family/Group Therapies, Intensive Outpatient Treatment, Partial Hospitalization
- NEW! MSHSL Sports Qualifying Physical Examination Clearance Form (.pdf)
- Nursing Home Communication Form and Instructions (zipped .doc) | Used for all programs
- Organizational Credentialing Form (.doc)
- Preauthorization Request for Psychological Testing Form (.doc)
- Provider Contract Application (.doc) | Potential Provider Application
- Provider Quality Complaint Reporting Form (.dot)
- Recommendation for Action DTR form (.doc) | MH-TCM Instructions for DTR (.doc) | Elderly Waiver Instructions for DTR (.doc)
- Voluntary Sterilization Pamphlet & Consent Form (Men) (.pdf)
- Voluntary Sterilization Pamphlet & Consent Form (Women) (.pdf)
- New! Zostavax (shingles) Claim form (.pdf)
Medicaid Pharmacy Forms
Medicare Pharmacy Forms