Frequently Used Forms

The files below are in PDF format ()

MI Interpreter Request Form

Health Education Referral Form

Claims Dispute Request Form

Provider Addition Roster

Submitting Electronic Data Interchange (EDI) Claims

CAHPS Provider Brochure

Provider Change Form

Approved Attending, Ordering and Referring Specialties 

W-9 Form

ADA Attestation Form

Ownership and Control Disclosure Form

2023 Prior Authorization Guide - Effective 4/1/23
2023 Prior Authorization Matrix - Effective 4/1/23
Q1 2023 PA Matrix including NCH Cardiology Management Program - Effective 3-1-2023
2023 Prior Authorization Guide - Effective 1/1/23
2023 Prior Authorization Guide - Medicare - Effective 1/1/23
2023 Prior Authorization Matrix - Effective 1/1/23
2022 Prior Authorization Guide - Effective 10/01/2022
2022 Prior Authorization Matrix - Effective 10/01/2022
2022 Prior Authorization Guide - Effective 07/01/2022
2022 Prior Authorization Guide - Medicare - Effective 07/01/2022
2022 Prior Authorization Matrix - Effective 07/01/2022
2022 Prior Authorization Guide - Effective 04/01/2022 
2022 Prior Authorization Guide - Medicare - Effective 04/01/2022 
2022 Prior Authorization Matrix - Effective 04/01/2022
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
FAQ
My Asthma Action Plan Card
Physician Office Laboratory Tests
Molina Medicaid Authorized Representative Designation Form
Notification of Pregnancy
Provider Request to Change PCP on Behalf of Member
Provider Initiated Member Transfer-Discharge Request
Provider Change Form Requirements and Guidelines
Provider Change Form
Consent for Sterilization
HRA Incentive
HRA Form
HRA Form - Spanish Version
Adult Foster Care (AFC) Reference Guide-Invoice Submission
Molina Coding Tips - Please click here.
 

 

 

 

The files below are in Excel format

MDCH Provider Forms and Other Resources

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