Provider Forms

• Forms
• Manual
• Provider Bulletins
• Provider Quick Points

To make it easy for you to work with CCStpa, you'll find a variety of forms here.

• Admission Notification Form
• Behavioral Health Admission Notification Form
• Behavioral Health LOCUS Assessment and Update Form
• CALOCUS Assessment and Update Form
• Cancer Clinical Trial Pre-Authorization Form
• Chiropractic Prior Authorization Request Form
• Concurrent Review of Chemical Dependency Treatment Form
• Durable Medical Equipment and Medical Supply Prior Authorization Request Form
• Early Intensive Behavioral Intervention (EIBI) Services Request Form
• EPNI Provider Automatic Payment Form
• Guide for Completing the CMS-1450 (Institutional Claims) Form
• Guide for Completing the CMS-1500 (Professional Claims) Form
• Home Health Pre-Authorization Request Form
• Individual Practitioner Provider Addition and Termination Form
• Medical Inpatient Hospital Admission Pre-Certification Form
• Minnesota Uniform Form for Prescription Drug Prior Authorization (PA) Requests and Formulary Exceptions
• Minnesota’s Universal Outpatient Mental Health/Chemical Health Authorization Form
• Non Participating Setup Request Form
• Out-of-Network Halfway House Admission Form
• Outpatient Physical, Occupational and Speech Therapy Pre-Authorization Request Form
• Pre-Certification Chemical Dependency Treatment Form
• Prior Authorization Request Form
• Provider Appeal Non-Minnesota Form
• Provider Clinic Location Closure Form
• Provider Contract Request Form
• Provider Demographic Change Form
• Provider Inquiry Form
• Provider TIN Change Form
• Psychological and Neurological Testing Request Form
• Quantity Limit Physician Fax Form
• Sample Waiver: General
• Skilled Nursing Facility Pre-Service Request Form
• Specialty Medication Prescription Form
• Step Therapy Authorization Request Form
• Transplant Pre-Service Request Form