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

Fill Online, Printable, Fillable, Blank Form completed by: First Name: Prior Authorization for (HealthPartners) Form

Use Fill to complete blank online HEALTHPARTNERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 19 minutes to complete

The Form completed by: First Name: Prior Authorization for (HealthPartners) form is 2 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 77 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your HealthPartners forms online.

BROWSE HEALTHPARTNERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Prior Authorization for Procedures and Surgery
Fax completed forms to (952)853-8713. Call Utilization Management (UM) at (952)883-6333 with questions. Incomplete forms will be returned.
Submit clinical documentation to support your request.
20-913603-913616 (9/20) © 2020 HealthPartners
DOB
Fax**
Phone*
Fax**
NPI
❑ Ofce ❑ Outpatient ❑ Inpatient
Phone*
Fax**
NPI
Fax**
Your business state
Your business zip
Last Name
Facility name
Clinic state
Clinic zip
Clinic state
Clinic zip
Facility state
Facility zip
*Condential voicemail required
**For outcome notication
Billing tax ID (claim may be rejected if incorrect)
Facility City
Facility street address
Phone*
Member information
First Name
Requester information
Form completed by: First Name
Your business name
Your business street address
Your business city
Phone*
Last Name
Provider last name
Provider last name
Ordering provider information
Provider first name
Specialty
Clinic name
Clinic street address
Clinic city
Clinic tax ID (claim may be rejected if incorrect)
Email
Procedural provider information
Provider first name
Specialty
Clinic name
Clinic street address
Clinic city
Clinic tax ID (claim may be rejected if incorrect)
Email
Facility site for procedure or surgery
MI
HealthPartners ID #
20-913603-913616 (9/20) © 2020 HealthPartners
Will waiting the standard review time seriously jeopardize member’s health, life or ability to regain maximum functioning? yes no
Procedure code(s)
Procedure(s) or surgery description
Proposed date of procedure
Procedure or surgery
Only include codes requiring prior authorization; other codes will not be addressed
P
rimary diagnosis code
Secondary diagnosis code
Updated last on 04/27/2021 Member Name
HealthPartners ID#
Description
Description
Clinical reason for urgency (not scheduling issues)
or TBD
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 March 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document