Forms
We want you to have easy access to forms you need. Listed below are common forms you may use as a Molina MyCare Ohio 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 MyCare Ohio Medicaid, a provider, your care or how we give you care; to file an appeal if Molina MyCare Ohio Medicaid 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. (coming soon)
- Healthchek – to see what Healthchek services you need if you’re pregnant. Healthchek services help pregnant people stay healthy. (coming soon)
- Pharmacy Direct Member Reimbursement Form - If you have paid out of pocket for a pharmacy product, you may be eligible for a reimbursement. Contact Member Services for more details.
If you need help filling out a form or have questions, call Member Services at (855) 687-7862 (TTY 711), Monday to Friday, 8 a.m. to 8 p.m. local time.
Materials are also available in printed and alternative formats, such as large print, audio, or Braille. Call Member Services for help.