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
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 |
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.
How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal
Redetermination Form - Use this form to request a redetermination (appeal). Complete this form and mail or fax to:
Address: | 7050 S Union Park Center Drive Suite 200 | |
Midvale, Utah 84047 | ||
Fax: | (866) 290-1309 | |
|
You may also submit your Redetermination request form here online.
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
*Printed copies of information posted on our website are available upon request.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.