Forms

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If you have any questions, please contact Member Services.

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 Dual Options MyCare Ohio at:

Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020

How to Request Coverage Determination - 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 an online secure form by clicking here. You can also download this form and mail or fax to:

Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020

Fax: (614) 781-1474

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

Complete an online secure form by clicking here. You can also download this form and mail or fax to:

Molina Healthcare
Attn: Grievance and Appeals
P.O. Box 22816
Long Beach, CA 90801-9977

Fax: (614) 781-1474 

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.


Medicare.gov Complaint Form
- To download a blank copy of the Medicare Complaint Form, click here. You may also access additional information on Medicare’s website at www.medicare.gov

 

*Materials are also available in printed and alternative formats, such as large print, audio, or Braille.
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