Forms & publications for healthcare providers

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Prior authorization

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Product/network guides

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Date Sort ascending	Name
	Long Term Acute Care (LTAC) Facility Admissions Prior Authorization Request Form
	Childrens Residential Concurrent Request form
	Step Therapy Authorization - Only for SecureBlue (HMO) (PDF)
	Managed Care Referrals (PDF)
	MN Universal OP Mental/Chemical Health (fax to 651-662-0854) (PDF)
	Immunoglobulin Therapy Pre - Authorization Request Form (Medical Policy II-51) (PDF)
	Reduction Mammoplasty Commercial Pre-Authorization Request Form (Medical Policy IV-32) (PDF)
	Early Intensive Behavioral Intervention (EIBI) Services Pre-Authorization Request Form (PDF)
	Medical Policy Coverage Exception form
	Substance Use Disorder Concurrent Request Form (PDF)
	Formulary Exception and Tier Authorization - Only SecureBlue (HMO) (PDF)
	Substance Use Disorder Treatment Initial Authorization Request Form (PDF)
	MN Uniform Form for PA Requests and Formulary Exceptions
	Transplant Pre-Authorization/Prior Approval Request Form (PDF)
	Psychological and Neuropsychological Testing Pre-Authorization Request Form (PDF)
	Bariatric Surgery Commercial Pre-Authorization Request Form (Medical Policy IV-19) (PDF)
	Inpatient Rehabilitation & Skilled Nursing Facility Admissions Prior Authorization Request Form
	Childrens Residential Initial Authorization Request form
	Home Health Care Pre-Authorization/Prior Approval Request Form (PDF)
	Pre-Authorization (PA) Request Form (PDF)
	Infliximab Commercial Pre-Authorization Request Form (Medical Policy II-97) (PDF)
	MN Uniform Form for Medical Drug PA Request and Formulary Exceptions
	Inpatient Admission Notification and Prior Authorization Request Form (PDF)
	Botulinum Toxin Commercial Pre-Authorization Request Form (Medical Policy II-16)(PDF)

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