Provider Forms



Corrected Claim Billing Guide
Request for Claim Reconsideration
Dental Request for Claim Reconsideration – Please review the Dental Provider Manual
Return of Overpayment
In-Office Laboratory Test List
 In-Office Laboratory Test Archive


Prior Authorizations

 Medicare and MyCare Ohio Medicare PA Guide 2024

Medicare and MyCare Ohio Medicare PA Form 2024
Medicare and MyCare Ohio Medicare Pharmacy PA Form 2024
Medicare and MyCare Ohio Medicare BH PA Form 2024
Nursing Facility Request Form
 Psychological Testing Request 
 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 Prior Authorization Form


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


Notice of Medicare Non-Coverage (NOMNC)

Notice of Medicare Non-Coverage Form


Other Forms and Resources
Ohio Urine Drug Screen Prior Authorization (PA) Request Form
PAC Provider Intake Form
 Request for External Wheelchair Assessment Form

Non-Contracted Providers Information
 ODM Designated Provider and Non-Contracted Provider Guidelines
 Ohio Dental Provider Contract Request Form
Ohio Provider Contract Request Form*

*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 Update Form*
CAQH Provider Data Form
Request to Change Provider Form
Ownership and Control Disclosure Form

 *Add/change/term information for contracted providers/groups


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