HealthPartners Care Network 2026

1. Click ‘Get Form’ to open the HealthPartners Care Network form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, HealthPartners ID number, date of birth, and group number.
3. Next, indicate if care for the requested specialty is available within the UnityPoint Health or ACO specialty network. Select 'Yes' or 'No' and follow the prompts accordingly.
4. Provide a summary of any UnityPoint Health or ACO specialty providers that the patient has seen for this diagnosis, including their names, specialties, treatment dates, and outcomes.
5. In the 'Reason for Request' section, explain why services can only be provided by an out-of-network provider. Ensure you attach any necessary clinical documentation.
6. Complete the 'Requester Information' and 'Ordering Provider Information' sections with relevant details such as names, fax numbers, and specialties.
7. Finally, fill out the 'Service Information' section with proposed service dates, level of care required, diagnosis codes, and descriptions of services needed.

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