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, UT 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:       (562) 499-0618
              MAIL:      Molina Medicare
                              P.O. box 22816, Long Beach,
                              CA 90801-9977 

 

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 Medicare.gov Complaint Form

 

*You may request printed copies of all content posted on our website.

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