Frequently Used Forms

 

Appeals

 Grievance Consent Form
 Provider Appeal Form

 

Behavioral Health

 Behavioral Health Prior Authorization Form
 Combined MCE Behavioral Health Provider Primary Care Provider Communication Form

 

Contracting & Provider Network

 Provider Contract Request Form
 Wisconsin W9
 Provider Roster Template
 Provider Information Update Form

 

Credentialing

 Molina Healthcare of WI- Practitioner Application
 Molina Healthcare Health Delivery Organization (HDO) application
 Molina Healthcare of WI CAQH Credentialing Checklist

 My Choice Wisconsin by Molina Healthcare Attestation Form

 LTSS Credentiaing 101

 LTSS Credentialing FAQ

 

 

Claims and Adjustments

 Overpayment Form
 

Prior Authorization

 Evolent 2025 Codification List for Oncology/Radiology and Cardiology Prior Authorizations

  Q2 2025 Medicaid Prior Authorization Code Updates

 Q1 2025 Prior Authorization Guide

 Q1 2025 Medicaid Prior Authorization Code Updates

 Q4 2024 PA Code Updates

 Q3 2024 PA Code Updates

 Q2 2024 PA Code Updates

 Q1 2024 PA Code Updates

 2024 Medicaid PA Guide Request Form

 

 

  

 

Referral and Other Health Care Forms

 Peer to Peer and Provider Reconsideration Form
 Hospice Benefit Election Form
 National Diabetes Prevention Program Referral
 Authorization for Use and Disclosure of PHI
 Authorization for Use and Disclosure of PHI (Spanish)
 PNCC Provider Notification Form
 Case Management Referral Form
 Clinical Care Coordination Referral Form
 Pregnancy Notification Form