Provider Forms
Effective Jan. 1, 2026, Molina Healthcare of Ohio, Inc. will discontinue fax submissions of prior authorizations (PA). All requests for PA must be submitted through the Availity Essentials portal.
If you have questions, contact Provider Relations at OHProviderRelations@MolinaHealthcare.com.
Claims
Corrected Claim Billing Guide
Claim Reconsideration Request Form (Non-Clinical Claim Dispute)
Dental Request for Claim Reconsideration – Please review the Dental Provider Manual
Return of Overpayment
In-Office Laboratory Test List
Prior Authorizations
Appeal Representative Authorization Appointment of Representative Form Behavioral Health Respite Services PA Reference Guide
Medicaid/MyCare Authorization Form – Community Behavioral Health Authorization Reconsideration Form
Prior Authorization Code Changes
Pharmacy
Pharmacy Prior Authorization Form
Provider Contract Templates
Abortion, Hysterectomy and Sterilization
ODM Consent to Sterilization Form
Guidelines for Completing Consent to Sterilization Form
ODM Consent to Hysterectomy Form
ODM Abortion Certification Form
Other Forms and Resources
Ohio Urine Drug Screen Prior Authorization (PA) Request Form
Non-Contracted Providers Information
ODM Designated Provider and Non-Contracted Provider Guidelines
Ohio Dental Provider Contract Request Form
Ohio Provider Contract Request Form*
Ohio Provider Contracting Guide
*For first-time providers wanting to contract with Molina Healthcare of Ohio (MHO), or for existing MHO providers wanting to add a new product to their contract.
Contracted Providers Making Changes
Provider Information Form*
CAQH Provider Data Form
Ownership and Control Disclosure Form
*Add/change/term information for contracted providers/groups
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