Frequently Used Forms

The files below are in PDF format ()

ADA Attestation Form

Approved Attending, Ordering and Referring Specialties 

CAHPS Provider Brochure

Claims Dispute Request Form

Health Education Referral Form

MDHHS Qualified Clinical Trial Form

MI Interpreter Request Form

Molina Roster Example

Molina Roster Template

NUCC Taxonomy List

Ownership and Control Disclosure Form

Provider Change Form

Submitting Electronic Data Interchange (EDI) Claims

W-9 Form

Alternate Level of Care Request Form 
Behavioral Health Request Form 
MI Medicaid Synagis Authorization Form
Drug Prior Authorization Form
MI-Alternative Level of Care Authorization Form
Prior Authorization Form
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
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
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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