Secure Admin | REPORT IT
Provider Forms
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)
- Claim Reconsideration Form (.doc)
- Claim Recoupment or Adjustment Fax Form (.doc)
- CD Admission Form (.doc) For All Levels Of Care (Note: Used for all Chemical Dependency Treatment—Inpatient, Outpatient, Methadone; This form replaces the Government CD Admission Worksheet)
- CD Complexities Grid (.doc)
- CD Request Worksheet (.doc) (Note: Used by Rule 25 Assessors Only; This form replaces the Government CD Request Worksheet)
- 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)
- Hospice Notification Worksheet (.doc)
- Inpatient Notification Worksheet (.doc)
- Managed Care Referral Request Form
online form | .doc 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
- MH-TCM Eligibility Determination Notification Form (SCHA #1796)
- Mental Health Targeted Case Management Child/Adolescent Diagnostic Verification Form (DHS-6069B-ENG) (DHS web form)
- Mental Health Targeted Case Management Adult Diagnostic Verification Form (DHS-6069A-ENG) (DHS web form)
- Mental Health Targeted Case Management Universal Transfer Form (DHS-6063-ENG) (DHS web form)
- MH-TCM DTR Recommendation for Action form (.doc) | MH-TCM DTR sample form(.pdf) | MH-TCM DTR instructions(.pdf)
- MH-TCM Authorization to Release Protected Health Information to SCHA Form (.doc)
- MH-TCM Functional Assessment Adult Mental Health Case Management form fields sample template (.doc)
- MN State High School League 2011- 2012 SPORTS QUALIFYING PHYSICAL EXAMINATION CLEARANCE FORM (.pdf)
- 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
- Nursing Home Communication Form and Instructions (zipped .doc) | Used for all programs
- Organizational Credentialing Assessment Form (.pdf)
- Preauthorization Request for Psychological Testing Form (.doc)
- Provider Contract Application (.pdf) | Potential Provider Application
- Provider Quality Complaint Reporting Form (.dot)
- Recommendation for Authorization of Home Care Services (.pdf)
- Waiver Recommendation for Action DTR form (.doc) | Waiver Recommendation for Action DTR form Instructions (.pdf) | Waiver Recommendation for Action DTR procedures (.pdf)
- 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