Forms
![duals_forms_p](/members/oh/en-us/-/media/Molina/PublicWebsite/Images/members/common/en-us/Duals/duals_forms_p.jpg?h=231&w=347&la=en&hash=DF09FAE91CADDE56A8E31DD3449EC3D7)
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.