Type Size:
Members

Forms

If you have any questions, please contact Member Services.

The following forms may be helpful to you. Go to the appropriate link to download printable copies

icon PDF Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Medicare at:

  MAIL: Molina Medicare
    7050 Union Park Center, Suite 200
   

Midvale, Utah 84047
 

icon PDFCoverage Determination Request Form – Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy. Complete this form and mail or fax to:

  FAX: (866) 290-1309
  MAIL: Molina Medicare
    7050 Union Park Center, Suite 200
   

Midvale, Utah 84047
 

You may also submit your Coverage determination request form here online.

icon PDF How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal

icon PDF Redetermination Form - Use this form to request a redetermination (appeal).  Complete this form and mail or fax to:

  Address: 7050 S Union Park Center Drive Suite 200
  Midvale, Utah 84047
  Fax: (866) 290-1309
   

You may also submit your Redetermination request form here online.

icon PDF Pharmacy Direct Member Reimbursement Form - Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.

Grievance and Appeal forms & the Medicare.gov Complaint Form

 

*Printed copies of information posted on our website are available upon request. 

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

This link will take you away from the Medicare section of MolinaHealthcare.com

This link will take you away from the Dual Options section of MolinaHealthcare.com

You are about to leave the Molina Healthcare website.

This link will take you away from the Dual Options section of MolinaHealthcare.com

This link will take you away from the Medicare section of MolinaHealthcare.com

You are leaving the Molina Healthcare website. Are you sure?

This information is for Doctors and
Health Care Professionals only.

X Please wait. Washington info is loading. Cancel