Molinalogo

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.

Provider Services Phone: (855) 838-7999
Provider Relations Email: SWHProviderRelations@molinahealthcare.com

Prior Authorization Forms

 Medicare PA Guide

 Medicare PA Form

 Medicare BH PA Form

 SNF Enhanced Auth Form

Pharmacy & Prescription Drug Forms

 Online Request for Medicare Part D Prescription Drug Coverage

 Online Request for Medicare Part D Redetermination

 Prescription Coverage Determination Form

 Redetermination Request Form

Claims

 Claim Reconsideration Form

 Provider Early Reversal Permission Form

Contracting/Update Forms

 Provider Contract Request Form

 Provider Information Update Form

 Contract Copy Request Form

 CAQH Provider Data Form

New Supplier Setup

New Supplier Setup Form

Molina Supplier Diversity policy can be found here. Any questions please email mhivendorhelp@molinahealthcare.com or call (888) 562-5442.