Frequently Used Forms

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

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