Forms
If you have any questions, please contact Member Services.
Grievance and Appeal Form - Use this form to request a redetermination (appeal) or a grievance. Complete this form and mail or fax to:
Molina Healthcare of Ohio, Inc.
Grievance and Appeals Unit
P.O. Box 182273
Chattanooga, TN 37422
Fax: (866) 713-1891
If you have someone submit the form for you, you must give your consent in the form.
How to File a Grievance
How to Appeal a Denial of Service
Pharmacy Direct Member Reimbursement Form - If you have paid out of pocket for a pharmacy product, you may be eligible for a reimbursement. Please contact the Member Services Department for further details.
Materials are also available in printed and alternative formats, such as large print, audio, or Braille.