Molina Healthcare Providers - Frequently Used Forms

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.

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

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

In-Plan Referral Form

Disease Management Programs

Step Therapy Criteria/Quantity Limits

Step-therapy (previous prescribing of another medication) and quantity limits are methods to control usage of certain drugs without requiring a prior authorization. The abbreviations for step-therapy (ST) and quantity limits (QL) are noted in the pdf icon Brand-Name Drug Formulary as applicable and found on the drug list page.

pdf icon Step-Therapy Criteria/Quantity Limits

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