Frequently Used Forms
The files below are in PDF format (
) :
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
W9
Copy of IRS 147-C Letter
Liability Insurance
Business License
Provider Roster
New Facility Contract
Letter of Intent
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
Prior Authorization Requirements:
Physical Health
Behavioral Health
Long Term Support Services
Centennial Care Behavioral Health Critical Incident Report Form
Additional Forms :
ESI Questionnaire
Facet Questionnaire
Member Authorization to Release PHI Forms