Provider Forms
Medical Services
Acupuncture Prior Authorization Request Form (Effective 8-8-2022)
Birth Notification Form for Prepaid Medical Assistance Plan and MinnesotaCare member
Durable Medical Equipment/Supply Prior Authorization Form
General Prior Authorization Request Form
Genetic Testing Prior Authorization Form
Hospice Election Form
Pre-Determination Request Form
Transplant Notification Form
Universal Health Plan/Home Health Agency Prior Authorization Request Form
Mental Health and Substance Use Disorder Services
Concurrent Review Form for Withdrawal Management
Mental Health Outpatient
Notice of Admission Form for Mental Health Inpatient or Residential
Notice of Admission Form for Substance Use Disorder Inpatient or Residential
Notice of Admission Form for Withdrawal Management
Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI)
Prior Authorization Form for Out-of-Network Providers
Prior Authorization Form for Psychiatric Residential Treatment Facilities (PRTF)
Substance Use Disorder Treatment Outpatient
Pharmacy
Medical Injectable Drug Authorization form
Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions
Care Coordination Referral Form
Care Management Referral Form - PDF
Care Management Referral Form - Word
Complex Case Management Referral Form - PDF
Complex Case Management Referral Form - Word
Health Connect 360 Referral Form
Medical Necessity Criteria Request Form
Mental Health & Substance Use Disorder Case Management Referral Form
Intensive Community Based Services (ICBS) Referral Form
Add or update a facility or location form
Advance Recipient Notice of Non-covered Service/Item (DHS)
Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) - If you would like to begin receiving funds and remits electronically, complete the Provider Payment and Remittance Request Form within the UCare Provider Portal.
Legacy Provider Claim Reconsideration Request Form
Online Provider Claim Reconsideration Form
W-9
Credentialing and Recredentialing
Initial Credentialing Application
MN Uniform Facility Credentialing Application
Uniform Re-Credentialing Application
Join Our Network
FDR Attestation
FDR Compliance Program Requirements
Site/Practitioner List
Provider Directory & Subdirectory Questionnaire
UCare Contract Intake Form
W-9
Manage Your Information - Add/Change/Term
Add a facility or location
Add a non-credentialed practitioner
Change a non-credentialed practitioner
Change or update your facility profile (tax ID, legal name, ownership, address, phone, NPI)
Disclosure of Ownership Form
MN Uniform Practitioner Change Form
PCA UMPI Add Form
PCA UMPI Change Form
PCA UMPI Term Form
Remove an organization or close a location
Term a non-credentialed practitioner
Portico data set-up
Provider Notification/Change/Update/Termination Third-Party Agreement
UCare Continuity of Care Document
Medical Injectable Drug Authorization form
Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions
Non-participating Provider Request Form
Other forms for Pharmacy are available based by product, please see the specific pharmacy page for the exact forms.
Specialty Referral Form
Prescribing Privileges for PCP Partners
Restricted Recipient Program Intake Form
UCare Individual & Family Plans Medical Referral for UCare Restricted Member Enrollee
UCare Individual & Family Plans Prescribing Privileges for PCP Partners
UCare Individual & Family Plans Restricted Member Program Intake Form
Universal Referral Form