Frequently Used Forms
Molina Healthcare appreciates your commitment and dedication to serving our Arizona Medicaid members. To make it easier for you to focus on providing great care to our Molina members, we’ve compiled our provider forms all in one place for you to access.
Click on the link to the forms you need, then download a copy and follow the instructions on the form.
- AHCCCS Drug List
- Molina Drug List
- Crisis Response Network
Crisis Response Network Provider Submission Portal
- Crisis Response Network Provider Submission Portal Announcement
- Crisis Response Network Provider Submission Portal Visual Reference Guide (Coming Soon)
- EPSDT Coding Guide (coming soon)
- Network Management Forms
- Utilization Management
- Pharmacy
- EPSDT
EPSDT Tracking Forms
- EPSDT Tracking Forms Cover Sheet and Instructions
- EPSDT Tracking Form 3-5 Days Old
- EPSDT Tracking Form 1 Month Old
- EPSDT Tracking Form 2 Months Old
- EPSDT Tracking Form 4 Months Old
- EPSDT Tracking Form 6 Months Old
- EPSDT Tracking Form 9 Months Old
- EPSDT Tracking Form 12 Months Old
- EPSDT Tracking Form 15 Months Old
- EPSDT Tracking Form 18 Months Old
- EPSDT Tracking Form 24 Months Old
- EPSDT Tracking Form 30 Months Old
- EPSDT Tracking Form 3 Years Old
- EPSDT Tracking Form 4 Years Old
- EPSDT Tracking Form 5 Years Old
- EPSDT Tracking Form 6 Years Old
- EPSDT Tracking Form 7-8 Years Old
- EPSDT Tracking Form 9-12 Years Old
- EPSDT Tracking Form 13-17 Years Old
- EPSDT Tracking Form 18-21 Years Old
- Women's/Maternity
- Newborn Notification Form
- Notification of Pregnancy Form
- Pregnancy Termination Form Exhibit 410-5*
(Form must be submitted via email on a secure server and password protected to the MCH/EPSDT Program Manager at MCCAZ-PregnancyTerm@MolinaHealthcare.com) - Consent to Sterilize Form - 420A*
(Form must be submitted via email on a secure server and password protected to the MCH/EPSDT Program Manager at MCCAZ-PregnancyTerm@MolinaHealthcare.com)
- Other
- Adult System of Care – Nine Guiding Principles
- Authorization to Use and Disclose (AUD) Form
- Children’s System of Care – Vision and Guiding Principles
- General Consent Form
- Out-of-Home Placement for Behavioral Health Treatment Checklist
- PCP Change Request Form (English | Spanish)
- Provider Claim Information Form
- Provider Credentialing Checklist
- Provider Demographic Update Form
- Provider Referral for Care Management Form
- Seclusion and Restraint Reporting Form
- Weekly Missed Provider Appointments Form
- Archived
- Prior Authorization Code/Benefit Exceptions
- Prior Authorization Code List (Revised February 1, 2021)
- 2021 NIA UM Review Matrix
- 2021 NIA Spine Surgery UM Review Matrix
- 2021 NIA IPM UM Review Matrix
J Code Prior Authorization ChangesEffective September 1, 2020, the following medications require prior authorization:
J CODE
J CODE DESCRIPTION
J1599
INJECTION, IMMUNE GLOBULIN (IVIG)
J9042
INJECTION, BRENTUXIMAB VEDOTIN, 1MG (ADCETRIS)
J9228
INJECTION, IPILIMUMAB, 1 MG (YERVOY)
J9271
INJECTION, PEMBROLIZUMAB, 1 MG (KEYTRUDA)
J9312
INJECTION, RITUXIMAB, 10 MG (RITUXAN)
Q5116
INJECTION, TRASTUZUMAB-QYYP, 10 MG (BIOSIMILAR TO TRAZIMERA)
J9355
INJECTION, TRASTUZUMAB, EXCLUDES BIOSIMILAR, 10 MG (TRAZIMERA)
J1930
INJECTION, LANREOTIDE, 1MG (SOMATULINE)
J9043
INJECTION, CABAZITAXEL, 1MG (JEVTANA)
J3101
INJECTION, TENECTEPLASE (TNKASE)
J9305
INJECTION, PEMETREXED, 10 MG (ALIMTA)
J9039
INJECTION, BLINATUMOMAB (BLINCYTO)
