Member Forms

We want you to have easy access to forms you need. Listed below are common forms you may use as a Molina Healthcare Medicaid member. Click on the form to access a PDF version you can download to print off and fill out or fill out on your device.

A description of the form and its use are listed. Look for instructions or details on the form. The instructions will tell you where to return the form or who to contact if you have questions.

Forms

  • Advance Directives – to make your wishes known regarding medical treatment in the case you are unable to communicate them yourself to a doctor.
  • Authorized Representative – to give permission for someone to make health care decisions on your behalf.
  • Change of Address (County) – to send address changes to the United States Postal Service (USPS).
  • Change of PCP – to submit a request to change your primary care provider (PCP).
  • Grievance/Appeal Request Form – to file a grievance (complaint) about Molina Healthcare, a provider, your care or how we give you care; to file an appeal if Molina Healthcare denies, reduces or suspends your service or claim.
  • Health Risk Assessment – to see what unique needs you have so we can connect you with support and services.
  • Healthchek – to see what Healthchek services you or your child needs. Healthchek services help children and pregnant people stay healthy and reduce the chance of sickness.

 

If you need help filling out a form or have questions, call Member Services at (800) 642-4168 Monday to Friday, 7 a.m. to 7 p.m..