Forms

Agency appointment request

* Required fields.

To qualify as an agency and become contracted with Molina Marketplace, the agency must:

Have a minimum 1 year experience selling ACA products
Hold active license in all states where agency and downline agents plan to sell Molina Marketplace
Contract 50+ downline agents with Molina Marketplace
Be capable of paying all agent level commissions
Commit to writing 1,500+ Molina Marketplace policies per year

* Agency Name

* Agency NPN

* Agency Tax ID

* Principal First Name

* Principal Last Name

* Agency Contact Number

* Principal Email

* Principal NPN

* Agency Business Address

* City

* State

* Zip

* By checking this box, you are agreeing that your agency meets these requirements, and that you are the Principal Agent of your agency.

By checking this box, you are agreeing that your agency meets these requirements, and that you are the Principal Agent of your agency.

Agent Appointment Request

Sign up to receive email updates from Molina Healthcare about your state billing requirements, authorization changes, quality improvement initiatives, training and other important information.

Event Participation Request Form

This form is used to request that Molina Healthcare of South Carolina participate in your upcoming event.

*Denotes Required Fields

1South Carolina Event
2Contact Information
3Event Information
4Organization Information
5Volunteer Opportunities

South Carolina Event

* Is this event in South Carolina?

Yes

California Provider Network - Ask Health Education

Do you have a question about Health Management Services and/or Resources? If you are Molina provider, you may send your questions pertaining to Health Management Services/Resources to MHC 's Health Education department. Fill out the form below! * Indicates a required field.

* First Name

* Last Name

* Phone Number (Including Area Code)

* Email Address

* Type of Facility

If other, please specify

* Enter your question here

Your question can only be answered if you are currently a contracted provider/practitioner with Molina Healthcare.

Please press submit only once - it may take a moment for your information to process.

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use

Please press submit only once - it may take a moment for your information to process.

Ask the C & L Specialist

Provider Relations

* First Name

* Last Name

Phone Number (Including Area Code)

* Email Address

Job Description

If other, please specify

Type of Facility

If other, please specify

* Is this question confidential?

Yes

The responses to confidential questions will not be posted online.

* Enter your question here

Your question can only be answered if you are currently a contracted provider/practitioner with Molina Healthcare.

Please press submit only once - it may take a moment for your information to process.

Note: The information provided on this website is for information purposes only and is not a substitute for medical advice or treatment of health care providers. No individual should make any medical decisions based on information provided here. If you have a specific health care needs, or for complete health information, please see a doctor or other health care provider

Discover ICHRA with Molina Healthcare

Molina Healthcare’s Individual Coverage Health Reimbursement Arrangement (ICHRA) helps employers offer health benefits with more flexibility and cost control. It’s a smart choice for all types of teams, including those with remote or hybrid employees—because workers can choose plans that fit their location, needs, and budget.

Are you interested in becoming a member?

Need help shopping for a plan? Please provide your information and one of our product experts will call you.

Subscribe for Email Updates

Sign up to receive email updates from Molina Healthcare about your state billing requirements, authorization changes, quality improvement initiatives, training and other important information.

Website Feedback Form

Tell us about your experience. Your feedback helps us improve our website’s design and functionality.

Please do not include any personal health information (PHI/PII).

Agency appointment request

* Required fields.

To qualify as an agency and become contracted with Molina Marketplace, the agency must:

Have a minimum 1 year experience selling ACA products
Hold active license in all states where agency and downline agents plan to sell Molina Marketplace
Contract 50+ downline agents with Molina Marketplace
Be capable of paying all agent level commissions
Commit to writing 1,500+ Molina Marketplace policies per year

* Agency Name

* Agency NPN

* Agency Tax ID

* Principal First Name

* Principal Last Name

* Agency Contact Number

* Principal Email

* Principal NPN

* Agency Business Address

* City

* State

* Zip

* By checking this box, you are agreeing that your agency meets these requirements, and that you are the Principal Agent of your agency.

By checking this box, you are agreeing that your agency meets these requirements, and that you are the Principal Agent of your agency.

Event Participation Request Form

This form is used to request that Molina Healthcare of South Carolina participate in your upcoming event.

*Denotes Required Fields

1South Carolina Event
2Contact Information
3Event Information
4Organization Information
5Volunteer Opportunities

South Carolina Event

* Is this event in South Carolina?

Yes

California Provider Network - Ask Health Education

* First Name

* Last Name

* Phone Number (Including Area Code)

* Email Address

* Type of Facility

If other, please specify

* Enter your question here

Your question can only be answered if you are currently a contracted provider/practitioner with Molina Healthcare.

Please press submit only once - it may take a moment for your information to process.

Ask the C & L Specialist

Provider Relations

* First Name

* Last Name

Phone Number (Including Area Code)

* Email Address

Job Description

If other, please specify

Type of Facility

If other, please specify

* Is this question confidential?

Yes

The responses to confidential questions will not be posted online.

* Enter your question here

Your question can only be answered if you are currently a contracted provider/practitioner with Molina Healthcare.

Please press submit only once - it may take a moment for your information to process.

Discover ICHRA with Molina Healthcare

Are you interested in becoming a member?

Need help shopping for a plan? Please provide your information and one of our product experts will call you.

Subscribe for Email Updates

Sign up to receive email updates from Molina Healthcare about your state billing requirements, authorization changes, quality improvement initiatives, training and other important information.

Website Feedback Form

Tell us about your experience. Your feedback helps us improve our website’s design and functionality.

Please do not include any personal health information (PHI/PII).

Loading component...

Loading component...

Loading component...

Loading component...

Loading component...

Loading component...

Loading component...

Loading component...

Subscribe for Email Updates

Loading component...

Loading component...

Loading component...

Loading component...

Subscribe for Email Updates