Frequently Used Forms

The files below are in PDF format ()

Health Education Referral Form

Claims Dispute Request Form

Healthcare Services Leadership Contact List

Provider Addition Roster

Submitting Electronic Data Interchange (EDI) Claims

CAHPS Provider Brochure

Provider Change Form

2022 Prior Authorization Guide - Effective 01/01/2022
2022 Prior Authorization Guide - Medicare - Effective 01/01/2022
2022 Prior Authorization Matrix - Effective 01/01/2022
2021 Prior Authorization Guide - Effective 10/01/2021
2021 Prior Authorization Guide - Medicare - Effective 10/01/2021
2021 Prior Authorization Matrix - Effective 10/01/2021
2021 Prior Authorization Guide - Effective 07/01/2021 
2021 Prior Authorization Guide - Medicare - Effective 07/01/2021 
2021 Prior Authorization Matrix - Effective 07/01/2021 
2021 Prior Authorization Guide  - Effective 04/01/2021 
2021 Prior Authorization Guide - Medicare - Effective 04/01/2021
2021 Prior Authorization Matrix - Effective 04/01/2021 
2021 Prior Authorization Guide - Effective 01/01/2021
2021 Prior Authorization Guide - Medicare - Effective 01/01/2021
2021 Prior Authorization Matrix - Effective 01/01/2021
2021 Prior Authorization Service Request Form - Effective 01/01/2021
2020 Prior Authorization Guide - Effective 10/01/2020
2020 Prior Authorization Guide - Medicare - Effective 10/01/2020
2020 Prior Authorization Matrix - Effective 10/01/2020
2020 Prior Authorization Matrix - Effective 07/01/2020
2020 Prior Authorization Guide - Effective 07/01/2020
2020 Prior Authorization Guide - Medicare - Effective 07/01/2020
2020 Prior Authorization Matrix - Effective 04/01/2020
2020 Prior Authorization Guide - Effective 04/01/2020
Prior Authorization Guide - Medicare - Effective 04/01/2020
2020 Prior Authorization Matrix - Effective 01/01/2020
2020 Prior Authorization Guide - Effective 01/01/2020
Prior Authorization Guide - Medicare - Effective 01/01/2020
2019 Prior Authorization Matrix - Effective 10/01/2019
2019 Prior Authorization Guide - Effective 10/01/2019
Prior Authorization Guide - Medicare - Effective 10/01/2019
2019 Prior Authorization Matrix - Effective 07/01/2019
2019 Prior Authorization Guide - Effective 07/01/2019
2019 Prior Authorization Matrix - Effective 04/01/2019
2019 Prior Authorization Guide - Effective 04/01/2019
2019 Prior Authorization Matrix - Effective 01/01/2019
2019 Prior Authorization Guide - Effective 01/01/2019
MI Medicaid Synagis Authorization Form
Drug Prior Authorization Form
MI-Alternative Level of Care Authorization Form
Prior Authorization Form
MI-OB Notification Form
HRA Form
HRA Form - Spanish Version
Community Connector Referral Guide
Community Connector Referral Form
Home Health Patient Drive Groupings Model (PDGM) FAQs
Home Care FAQ
Provider Addition Roster
Molina Healthcare of Michigan Provider Contract Request Form
Web Portal Administrator Change Form
2018 Cultural Competency Training Attestation
FAQ
My Asthma Action Plan Card
Physician Office Laboratory Tests
Molina Medicaid Authorized Representative Designation Form
Notification of Pregnancy
Provider Request to Change PCP Form
Provider Change Form Requirements and Guidelines
Provider Change Form
Consent for Sterilization
Certification for Induced Abortion
HRA Incentive
HRA Form
HRA Form - Spanish Version
Adult Foster Care (AFC) Reference Guide-Invoice Submission
Molina Coding Tips - Please click here.
Maternal Infant Health Program

 

 

 

The files below are in Excel format

MDCH Provider Forms and Other Resources

icon PDF Adobe Acrobat Reader is required to view the file(s) above. Download a free version.