Mental Health & Substance Use Disorder Services Authorizations
UCare Individual & Family Plans and UCare Individual & Family Plans with M Health Fairview
Authorizations and Notifications Requirements
Review UCare Individual & Family Plans Requirements:
Forms & Information
Mental Health Outpatient
Substance Use Disorder Treatment Outpatient
Prior Authorization Form for Out-of-Network Providers
Prior Authorization Form for Early Intensive Developmental & Behavioral Intervention (EIDBI)
Prior Authorization Form for Psychiatric Residential Treatment Facilities (PRTF)
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
Concurrent Review Form for Withdrawal Management
Rule 25 Assessment and Placement Summary Form
The forms below may be used when referring members to the UCare Individual & Family Plans Restricted Member Program:
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
This form is intended to communicate patient referrals between medical and behavioral health providers.
Universal Referral Form
Authorization Contact Information
UCare Mental Health and Substance Use Disorder Services
Phone (toll free): 1-833-276-1185
Fax (local): 612-884-2033
Fax (toll free): 1-855-260-9710
Provider Resources
View Authorization Requirements & Forms For Another Plan
*UCare Medicare Plans include Aware, Classic, Complete, Essentials Rx, Prime, Standard, Value and Value Plus,
Advocate Choice, Advocate Choice Plus and UCare Medicare Supplement.
UCare Individual & Family Plans include Core, Bronze, Bronze HSA, Silver, Silver HSA and Gold; and
UCare Individual & Family Plans with M Health Fairview Bronze, Bronze HSA, Silver, Silver HSA and Gold.