Forms
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact Provider Services at (844) 236-1464.
- Authorizations/Utilization Management
To submit a prior authorization request:
1. Log in to Availity
2. Select Patient Registration from the top navigation
3. Then, select Auth/Referral Inquiry or Authorizations
At this time, you are not required to submit all prior authorization requests using Availity, but we do encourage you to use this method for quicker authorization turnaround times. Molina Iowa UM Fax: (877) 319-6828.
Universal Prior Authorization:Medicaid Supplemental Information PA Form
Inpatient Medicaid Prior Authorization Form
Iowa Medicaid Resources
Please download these guides for Molina fax information:
Inpatient Medicaid PA Resource Guide
Outpatient Medicaid PA Resource Guide
Prior Authorization Code ListsPrior Authorization Reconsiderations and Appeals
- Claims Forms
* Once complete, please fax form to Molina Healthcare of Iowa Appeals and Grievances at 1-855-275-3082.
- Overpayment Forms
- Provider Network Forms
- Pharmacy Forms
- Abilify Mycite PA Form
- ACL Inhibitors PA Form
- Acute Migraine Treatments PA Form
- Adbry PA Form
- Age Edit Override Codeine Tramadol PA Form
- Alpha-1 Proteinase Inhibitors PA Form
- Ampyra PA Form
- Amylino Mimetic PA Form
- Antidepressants PA Form
- Antidiabetics Noninsulin PA Form
- Antiemetic Products PA Form
- Anti-Fungal PA Form
- Antihistamines PA Form
- Apremilastotezla PA Form
- Baclofen PA Form
- Bed PA Form
- Benzodiazepines PA Form
- Biologicals Arthritis PA Form
- Biologicals Axial Spondyloarthritis PA Form
- Biologicals HS PA Form
- Biologicals IBD PA Form
- Biologicals Plaque Psoriasis PA Form
- Bronchitol PA Form
- Bylvay PA Form
- Bystolic PA Form
- Camzyos PA Form
- Cholbam PA Form
- CNS Stimulants Atomoxetine PA Form
- CNS Stimulants PA Form
- Ivabradine Corlanor PA Form
- Cystic Fibrosis Agents Oral PA Form
- Deferasirox Exjade PA Form
- Doac PA Form
- Dojolvi PA Form
- Dupixent PA Form
- Duplicate Therapy Edit PA Form
- Emflaza PA Form
- Empaveli PA Form
- Enspryng PA Form
- Erythropoiesis-Stimulating Agents PA Form
- Eucrisa PA Form
- Evrysdi PA Form
- Extended-Release Formulation PA Form
- Fentanyl Short Acting Products PA Form
- Fifteen Day Supply Override PA Form
- GLP-1 Agonist Basal Insulin Combination PA Form
- GnRH Receptor Antagonist Oral PA Form
- Granulocyte Colony Stimulating Factor PA Form
- Growth Hormone PA Form
- Hematopoietic Chronic ITP PA Form
- Hepatitis C Treatments PA Form
- High Dose Opioids PA Form
- IL-5 Antagonists PA Form
- Initial Days Supply Limit Override PA Form
- Isotretinoin Oral PA Form
- Janus JAK Inhibitors PA Form
- Kerendia PA Form
- Ketorolac PA Form
- Kuvan PA Form
- Lidocaine Patch PA Form
- Livmarli PA Form
- Long-Acting Opioids PA Form
- Methotrexate Injection PA Form
- Mifepristone Korlym PA Form
- Miscellaneous PA Form
- Modified Formulations PA Form
- Muscle Relaxants PA Form
- Naloxone Nasal Spray PA Form
- New Market Drugs PA Form
- Nocturnal Polyuria Treatments PA Form
- Non-biologic Agents Ulcerative Colitis PA Form
- Non-Parenteral Vasopressin Derivatives PA Form
- Non-Preferred Drug PA Form
- NSAID Drugs PA Form
- Nuedexta PA Form
- Ophthalmic Agents Presbyopia PA Form
- Oral Constipation Agents PA Form
- Oral Glucocorticoids for DMD PA Form
- Oral Immunotherapy PA Form
- Multiple Sclerosis Agents Oral PA Form
- Ospemifene PA Form
- Oxbryta PA Form
- Palforzia PA Form
- Pavilizumab PA Form
- PCSK9 Inhibitors PA Form
- Pirfenidone And Nintedanib PA Form
- Potassium Binders PA Form
- Prevymis PA Form
- Proton Pump Inhibitors PA Form
- Pulmonary Arterial Hypertension Agents PA Form
- Qelbree PA Form
- Quantity Limit Override PA Form
- Rayaldee PA Form
- Regranex PA Form
- Repository Corticotropin Injection PA Form
- Roflumilast Daliresp PA Form
- Sedative/Hypnotic Non-Benzodiazepine PA Form
- Select Anticonvulsants PA Form
- Selected Brand Name Drug PA Form
- Select Oncology Agents PA Form
- Select Preventative Migraine Treatments PA Form
- Short-Acting Opioids PA Form
- Sodium Oxybate Products PA Form
- Sotyktu PA Form
- Tasimelteon Hetlioz PA Form
- Testosterone Products PA Form
- Tezspire PA Form
- Topical Acne & Rosacea PA Form
- Topical Antifungals PA Form
- Topical Corticosteroids PA Form
- Topical Immunomodulators PA Form
- Verkazia PA Form
- Verquvo PA Form
- Viberzi PA Form
- Vijoice PA Form
- Vitamins, Minerals and Multiple Vitamins PA Form
- VMAT 2 Inhibitors PA Form
- Vorapaxar Zontivity PA Form
- Vusion Ointment PA Form
- Xolair PA Form
- Xifaxan PA Form
- Zurampic PA Form
- Zyvox PA Form
- Women’s Health Services
- Pregnancy Notification Form
Please view this Prenatal Care Guide for more details.
- Pregnancy Notification Form