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Click on the links below to access important member forms.

 

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.

 

 Appointment of Representative Form (CMS-1696)

 

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina One Care at:

 

Molina One Care
7050 Union Park Center, Suite 200
Midvale, UT 84047

 

Coverage 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.

 

You may submit your Coverage determination request form here online.

 

You may also complete the below form and mail or fax.

 

 2026 Molina One Care (HMO D-SNP)

Complete this form and mail or fax to: Address:		7050 S Union Park Center Drive, Suite 200 Midvale, Utah 84047
Fax:		(866) 290-1309

 

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

 

 2026 Molina One Care (HMO D-SNP)

 

Redetermination Form - Use this form to request a redetermination (appeal). You may submit your Redetermination request form here online.

You may also complete the below form and mail or fax.

 

 

 2026 Molina One Care (HMO D-SNP)

Complete this form and mail or fax to:

 

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

 

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.

 

 2026 Molina One Care (HMO D-SNP)

 

Grievance and Appeal forms & the Medicare.gov Complaint Form

 

Advance Directives Information Sheet: provides insight on Advance Directives.

 

 Advance Directives Information Sheet

You will receive your Member ID Card after your enrollment is confirmed

 

While you are a member, you must use your membership card whenever you get any services covered by this plan. It is also to be used for prescription drugs you get at network pharmacies.

 

If your plan membership card is damaged, lost, or stolen, you can request for a new card on your My Molina portal.

 

 

Created especially for Molina members. This important health news can help keep you and your family healthy.