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Frequently Used Forms

The files below are in PDF format (pdf icon) :

New Contract Requests:

Please note: All Providers/Groups must have an active New Mexico Medicaid ID number.

Please complete and provide the forms listed below and send directly to:

NMProviderContracting@MolinaHealthCare.Com or Fax: 505-798-7313

New Provider\Group Contract

Letter of Intent

Joint MCO Centennial Medicaid Disclosure Form

Practitioner Information Form (per provider providing services)

W9

Copy of IRS 147-C Letter

Liability Insurance

Business License

Molina Healthcare Attestation

Provider Roster

New Facility Contract

Letter of Intent

Health Delivery Organization Application

Facility Information Form

Joint MCO Centennial Medicaid Disclosure Form

W9

Copy of IRS 147-C Letter

Existing Contracts :

To add a new provider to a contracted group, please complete the forms below and send to:
MHNMCredentialing@MolinaHealthCare.Com or Fax: 505-798-7313

Practitioner Information Form

Joint MCO Centennial Medicaid Disclosure Form

Prior Authorization Requirements:

Drug Prior Authorization Request

Provider News Bulletin - Hep C

Uniform New Mexico HCV Checklist for Centennial Care

Physical Health

2018 Prior Authorization Guide and Form

Q1 2018 Prior Authorization Code List-Update 02012018


Behavioral Health

Initial Clinical Review Form

BH Clinical Review and Notification Forms Fax Sheet

Concurrent Clinical Review Form

Discharge Clinical Notification Form

Retrospective Clinical Review Form

BH Level of Care Guidelines

ABA Stage 3 Initial and Concurrent Form

ABA Level of Care Guidelines

ABA Specialty Care Provider Prior Authorization Form

Value Added Services Level of Care Guidelines

Long Term Support Services

Nursing Level of Care Notification Form

Nursing Level of Care Communication Form

Centennial Care Behavioral Health Critical Incident Report Form​

Behavioral Health Critical Incident Report Form

Additional Forms :

Appointment of Representative Form    
17 P Request Form    
Care Coordination/Case Management Form
CMS - 1500 Form
Disease Management Referral Form
ESI Questionnaire
Facet Questionnaire​
Formulary Addition Request Form
IRS Form W9    
Member Authorization to Release PHI Forms (en español)
PCP Change Form
Provider Reconsideration Request Form
Pregnancy Notification Form
UB04 Form
Vaccines for Children Bulletin and Attestation Form

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