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