Forms

If you have any questions, please contact Member Services.

The following forms may be helpful to you. Go to the appropriate link to download printable copies

icon PDF 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 Medicare at:

  MAIL: Molina Medicare
            7050 Union Park Center, Suite 200
            Midvale, Utah 84047

icon PDF 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. Complete this form and mail or fax to:

  FAX: (866) 290-1309
  MAIL: Molina Medicare
    7050 Union Park Center, Suite 200
   

Midvale, Utah 84047

You may also submit your Coverage determination request form here online.

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

icon PDF Redetermination Form   - Use this form to request a redetermination (appeal).  Complete this form and mail or fax to:

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

You may also submit your Redetermination request form here online.

icon PDF 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.

Grievance and Appeal forms & the Complaint Form

 

*Printed copies of information posted on our website are available upon request.

icon PDFAdobe Acrobat Reader is required to view the file(s) above. Download a free version