AUC Forms

Single, Uniform Home Care Prior Authorization (PA) Form (PDF)

This form was developed and approved by the AUC for requesting PA for Home Health Services covered by a health plan or a county-based purchasing plan. The form is NOT to be used for DHS FFS Home Health Services or for PCA services and is to be used ONLY for Home Health Services.

Claims Attachment Cover Sheet (including instructions) (DOC)

AUC Payer Contact Information (PDF) for faxing claims attachments

Claims Appeal Request Form (PDF)

Instructions (PDF)

AUC Payer Contact Information (PDF) for faxing appeals forms

This form is to be used when a provider is requesting a reconsideration of a previously adjudicated claim but there is no additional or corrected data to be submitted.

UFEF/Prescription Drug PA Request Form - fillable (PDF)

UFEF/Prescription Drug PA Request Form - non-fillable (PDF)

The form is intended primarily for use by prescribers, or those designated and authorized to act on behalf of prescribers, to:

• Request an exception to a prescription drug formulary.


• Request a prior authorization (PA) for a prescription drug.

Minnesota's Universal Outpatient Mental Health/Chemical Health Authorization Form (PDF)

SBAR Form (DOC)

Use this form in accordance with Policy #10 (PDF) to request that the AUC conduct work on a particular administrative simplification issue.

Purpose: To provide a formal communication method by which member organizations or non-member interested parties may request the AUC to consider working on a particular issue related to administrative simplification or to request clarification of Minnesota rules and regulations related to administrative simplification.

Complete a separate SBAR form for each individual issue that needs to be addressed.

Guide Work Request Form (DOC)

Use this form to suggest changes to uniform companion guides.