Provider Forms
Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us.
Provider Services Phone: (855) 838-7999
Provider Relations Email: SWHProviderRelations@molinahealthcare.com
2024 Prior Authorization Forms
Pharmacy & Prescription Drug Forms
Online Request for Medicare Part D Prescription Drug Coverage
Online Request for Medicare Part D Redetermination
Senior Whole Health (HMO D-SNP)
Prescription Coverage Determination Form
Senior Whole Health NHC (HMO D-SNP)
Prescription Coverage Determination Form
Senior Whole Health Medicare Choice Care (HMO)
Prescription Coverage Determination Form
Senior Whole Health Medicare Choice Care Select (HMO)
Prescription Coverage Determination Form
Claims
Provider Early Reversal Permission Form
Contracting/Update Forms
Provider Contract Request Form
Provider Information Update Form
New Supplier Setup
Molina Supplier Diversity policy can be found here. Any questions please email mhivendorhelp@molinahealthcare.com or call (888) 562-5442.