Fillable Form completed by: First Name: Prior Authorization for (HealthPartners)

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Form completed by: First Name: Prior Authorization for (HealthPartners)

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Prior Authorization for Durable Medical Equipment
Call Utilization Management (UM) at (952)883-6333 with questions. Incomplete forms will be returned. Su
bmit clinical documentation to
support your request.
20-913603-913616 (9/20) © 2020 HealthPartners
DOB
Fax**
Phone*
Fax**
NPI
Fax**
Your business state
Your business zip
Last Name
Clinic state
Clinic zip
Vendor state
Vendor zip
*Condential voicemail required
**For outcome notication
Billing tax ID (claim may be rejected if incorrect)
Phone*
Physician last name
Last
Name
Durable Medical Equipment
Primary diagnosis code
Secondary diagnosis code
MI
Member information
First Name
HealthPartners ID #
Requester information
Form completed by: First Name
Your business name
Your business street address
Your business city
Phone*
Ordering physician information
Physician first name
Specialty
Clinic Name
Clinic Street Address
Clinic City
Clinic tax ID (claim may be rejected if incorrect)
Vendor Information
Vendor name
Vendor street address
Vendor City
Description
Description
Email
Has requested item been provided to member? Yes No
If yes, please provide date:
20-913603-913616 (9/ 20) © 2020 HealthPartners
Updated last on 5/24/2021 Member Name
Request Information:
Item(s) Description
Cost
Start Date End Date
Modifier
HCPC
Note: Requests for prior authorization which are not submitted within 30 days of the date item
was dispensed could be subject to denial (vendor liability)
HomeLink Contracted Vendors: send this form to HomeLink
Telephone: (866)211-1995
Fax: (855)348-9970
If not contracted with HomeLink: send this form directly to
HealthPartners
Telephone: (952)883-6333
Fax: (952)853-8714
HealthPartners ID#
Please select modifier:
Please select modifier:
Please select modifier:
Please select modifier:
Please select modifier:
Please select modifier:
Please select modifier:
Comments:
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Form completed by: First Name: Prior Authorization for (HealthPartners)

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Completed 22 February 2022

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