Clinical & Other Resources

Forms

Claim Forms

• Claim Reconsideration Form
• Flu Shot Roster

Credentialing Applications

Note: Sanford Central Verification Office participates with the Minnesota Credentialing Collaborative, therefore accepts credentialing applications electronically through the site located at www.mncred.org.

• Facility Credentialing Application
• Practitioner Credentialing Application

Medical Management Forms

• Benefit Coverage Consideration Request Form
• Diabetes Eye Exam Consult Form
• Health Management Program Referral Form
• Medical Prior Authorization Request form
• Prescription Drug Prior Authorization Request and Formulary Exception Form
• Synagis - Drug Prior Authorization Request and Formulary Exception Form

Provider Demographic & Other Forms

• Member Authorization for Access to health Information (HIPAA) Form
• Provider Update/Change Form
• Third Party Release Privacy Authorization
• W-9 Form

Documents

• Prior Authorization List
• Claim Edit List
• eviti Oncology Authorization FAQ
• Sanford Health Plan ID cards
• Understanding Your Check Adjustment Report

Manuals

• Provider Manual
• Provider Onboarding Manual