Molina Healthcare Providers - Frequently Used Forms

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Frequently Used Forms

SALUD is a medical program that provides services at no cost or low-cost for people on Medicaid.

*The files below are in PDF format ( pdf icon ) and are also found in the Provider Manual.

Facet Questionnaire

ESI Questionnaire

Care Coordination/Case Management Form

Medication Prior Authorization Request

Suboxone Prior Authorization Form

Formulary Addition Request Form

Provider Reconsideration Request Form

CMS - 1500 Form

Member Authorization to Release PHI forms [English| en español]

Prenatal Program Referral Form

Prescription Drug Prior Authorization Criteria

Disease Management Referral Form

Prior Authorization Requirements

Prior Authorization Guide

Prior Authorization Exception Code List

Prior Authorization Request Form

Interested Providers

The forms below are for providers interested in becoming Molina Healthcare practitioners/providers.

PLEASE NOTE: The Disclosure Form must accompany the Provider Information and Facility Information Forms. Please fax completed forms to (505) 798-7313, or email directly to your designated Provider Service Representative. Provider Services Territory Map

Molina Healthcare Attestation

New Mexico Disclosure Form

Provider Information Form

Facility Information Form

Third Party Assessor (TPA) forms can be found under the corresponding links in the TPA area.

*The files below are in Word format ( word icon )

In-Plan Referral Form

Adobe Acrobat Reader is required to view the file(s) above. Download a free version.

Medicare callout

Medicare Now Available!

Are you eligible?

Molina now offers Medicare plans that provide all of the benefits covered under original Medicare and more.

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