Get the free Hennepin Health referral form Download - hennepinhealth

Hennepin Health Service Authorization Form For Specialty Services Not Available in Member Network Request Date Please complete this form and fax to: 6126776222 For additional information, please call

How to fill out hennepin health referral form

How to fill out hennepin health referral form:

Obtain the referral form:

1. Contact Hennepin Health or visit their website to download the referral form.
2. You may also request a physical copy of the form through mail or in-person.

Enter personal information:

1. Start by providing your full name, address, phone number, and date of birth.
2. Some forms may require additional information such as your social security number or insurance details.

Specify the referring provider:

1. Fill in the name, contact information, and specialty of the healthcare professional who is referring you.
2. If you don't have a specific provider in mind, you can contact Hennepin Health for assistance.

Describe the reason for the referral:

1. Clearly state the medical condition or issue for which you are seeking a referral.
2. Include any relevant medical history, symptoms, or diagnosis.

Select the specialist or facility:

1. Indicate the name and contact information of the specialist or healthcare facility you wish to be referred to.
2. If you are unsure, Hennepin Health can provide you with a list of approved specialists or facilities.

Provide any supporting documentation:

1. If you have any medical reports, test results, or documents relevant to the referral, attach them to the form.
2. These documents can help the referring provider and specialist understand your condition better.

Sign and date the form:

1. Once you have completed all the necessary sections of the referral form, sign and date it.
2. Make sure to review the form for accuracy before submitting it.

Who needs hennepin health referral form:

Individuals seeking specialized care:

1. Anyone who requires specialized medical care beyond the scope of their primary healthcare provider may need a Hennepin Health referral form.
2. This includes individuals with complex medical conditions, chronic illnesses, or specific healthcare needs.

Patients with health insurance through Hennepin Health:

1. Hennepin Health is a managed care organization that provides healthcare coverage to eligible individuals.
2. If you are a Hennepin Health member and your insurance requires a referral for certain services, you will need to fill out the referral form.

Individuals seeking covered services:

1. Some services or treatments may only be covered by Hennepin Health if they are obtained through a referral.
2. If you are unsure whether a specific service requires a referral, you can contact Hennepin Health or refer to your insurance policy.

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What is hennepin health referral form?

The Hennepin Health referral form is a document used to refer patients to specialists or other healthcare providers within the Hennepin Health network.

Who is required to file hennepin health referral form?

Healthcare providers and physicians within the Hennepin Health network are required to file the referral form.

How to fill out hennepin health referral form?

To fill out the Hennepin Health referral form, healthcare providers need to include patient information, reason for referral, and any relevant medical history.

What is the purpose of hennepin health referral form?

The purpose of the Hennepin Health referral form is to facilitate the coordination of care for patients within the Hennepin Health network.

What information must be reported on hennepin health referral form?

Patient demographics, reason for referral, medical history, and any relevant test results or imaging studies must be reported on the referral form.