Forms
We want you to have easy access to forms you need. Listed below are common forms you may use as a Molina Complete Care for MyCare Ohio 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.
If you need help filling out a form or have questions, call Member Services at (855) 665-4623, Monday to Friday, 8 a.m. to 8 p.m. local time.
Advance Directives – to make your wishes known regarding medical treatment in the case you are unable to communicate them yourself to a doctor.
Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf for 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 Complete Care for MyCare Ohio at:
Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020
Change of PCP – to submit a request to change your primary care provider (PCP).
Appeal Representative Form – Use this form to give your written consent to appoint someone else to act on your behalf for an appeal. (coming soon)
2026 Coverage Determination Request Form
2025 Coverage Determination Request 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. Ask us for a coverage determination by phone at (855) 665-4623 (TTY 711) 8 a.m. - 8 p.m. local time, Monday to Friday.
Mail or fax the form to:
Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020
Fax: (614) 781-1474
You can also complete our secure online form.
2026 How to Request a Redetermination
2025 How to Request a Redetermination – Please read this document to understand what you need to do to request an appeal.
2026 Request a Redetermination
2025 Request a Redetermination – You can also download this form and mail or fax it to:
Molina Healthcare
Attn: Grievance and Appeals
P.O. Box 22816
Long Beach, CA 90801-9977
Fax: (614) 781-1474
You can also complete our secure online form.
2026 Direct Member Reimbursement Form
2025 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.
Health Risk Assessment – To see what unique needs you have so we can connect you with support and services. (coming soon)
Medicare.gov Complaint Form
- Complete this form to file a complaint about Molina Complete Care for MyCare Ohio with the Centers for Medicare and Medicaid Services (CMS), You can find more 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. Call Member Services for help.
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