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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.

Provider Information Form
Facet Questionnaire
ESI Questionnaire
Prior Authorization Request Form
Care Coordination/Case Management Form
Medication Prior Authorization Request
Formulary Addition Request Form
Provider Reconsideration Request Form
CMS - 1500 Form
UB04 Form
Member Authorization to Release PHI forms [English| en español]
Prenatal Program Referral Form
IRS Form W9
Prescription Drug Prior Authorization Criteria
Prior Authorization Guideline/Matrix
Disease Management Referral 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

 

 

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