Provider Forms

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

2024 Prior Authorization Forms

icon PDF Medicare PA Guide

icon PDF Medicare PA Form

icon PDF Medicare BH PA Form

Pharmacy & Prescription Drug Forms

icon Online Request for Medicare Part D Prescription Drug Coverage

icon Online Request for Medicare Part D Redetermination

Senior Whole Health (HMO D-SNP)

icon Prescription Coverage Determination Form

icon Redetermination Request Form

Senior Whole Health NHC (HMO D-SNP)

icon Prescription Coverage Determination Form

icon Redetermination Request Form

Senior Whole Health Medicare Choice Care (HMO)

icon Prescription Coverage Determination Form

icon Redetermination Request Form

Senior Whole Health Medicare Choice Care Select (HMO)

icon Prescription Coverage Determination Form

icon Redetermination Request Form

 

Claims

icon Claim Reconsideration Form

icon Provider Early Reversal Permission Form

 

Contracting/Update Forms

icon Provider Contract Request Form

icon Provider Information Update Form

icon Contract Copy Request Form

icon CAQH Provider Data Form

 

New Supplier Setup

icon New Supplier Setup Form

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