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:

  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.

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

 

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

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