Provider Forms

Note: PDF forms require Adobe Acrobat Reader.

If you are a provider wanting to appeal a claim determination, please click here.

• Minnesota Credentialing Collaborative (MCC) Electronic Application (Use for Initial or Recred)
• Minnesota Uniform Credentialing Reapplication
• MN Uniform Practitioner Change Form
• MN Uniform Facility Credentialing Application

Medical Management - Fax Forms to 763-847-4014

• Clinical Trial Notification Form
• Continued SNF Stay Prior Authorization Form
• Continuity of Care Form
• Genetic Testing for Heritable Conditions Prior Authorization Form
• Home Health Agency Universal Prior Authorization Request Form
• Initial SNF Stay Prior Authorization Form
• Inpatient Hospital Admission Notification Form
• Inpatient Precertification / Prior Authorization Concurrent Review Form
• Long-Acting Opioid Prior Authorization Form
• Minnesota's Universal Outpatient Mental Health/Chemical Dependency Authorization Form
• Peer to Peer Discussion Request Form
• Pharmacy Medication Request Form
• Prior Authorization Form - Medical Services
• Provider Administered Infusion Injection Form (Buy & Bill)
• Radiation Therapy, Intensity Modulated (IMRT) Prior Authorization
• Radiofrequency Ablation Prior Authorization Form
• Radiofrequency Ablation Prior Authorization Form
• Synagis Authorization Form

Provider Relations - Fax Forms to assigned Provider Relations Representative or 763-847-4010 Attn: Provider Relations

• Facility Information Sheet
• Independent Therapy Provider Services Form
• Provider Information Change Form
• Supplemental Site Sheet
• Tax ID Change Notification Form