Molinalogo

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us. 

Claims Forms

 Participating Provider Claim Dispute Form

Provider Network Forms

 Provider Information Change Form

Request to Add a New Provider

Facility/HealthCare Delivery Organization (HDO)/Long Term Special Services (LTSS) Credentialing Application

Non-Participating Provider Forms

 Waiver of Liability Form
 Claim Appeal Request Form

Utilization Management Forms

 Medicare PA Guide
 Medicare PA Form
 Medicare BH PA Form
 Medicare Pharmacy PA Form

Behavioral Health Forms

 Psychological and Neuropsychological Assessment Supplemental Form

Pharmacy Forms

Passport Advantage (HMO D-SNP)

 2024 Rx Mail Order Form
 2024 Coverage Determination Request Form
 2024 Redetermination Form

Passport Medicare Choice Care (HMO)

 2024 Rx Mail Order Form
 2024 Coverage Determination Request Form
 2024 Redetermination Form