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

Molina Healthcare Prior Authorization Request Form and Instructions
Nursing Facility Request Form
Synagis (RSV) Authorization
Hospital/Private BH Practice PA Form
Hospital/Private BH Practice Reference Guide
Behavioral Health Respite Services PA Reference Guide
Psychological Testing Request
Medicaid/MyCare Authorization Form – Community Behavioral Health

Prior Authorization Code Lists

Prior Authorization (PA) Code List - Effective 7/1/2022 
Prior Authorization (PA) Code List - Effective 4/1/2022 
Prior Authorization (PA) Code List - Effective 3/1/2022
Archived PA Code Lists

Prior Authorization Reconsiderations and Appeals

Authorization Reconsideration Form
Appeal Representative Authorization

Did you know a PA Denial Reconsideration is faster than an appeal in most cases? The Appeal Representative Authorization form is not required when requesting a reconsideration.

Home Health Care

MyCare Ohio Uniform Authorization Request Form


Pharmacy Prior Authorization Form
Hepatitis Therapy Prior Authorization Request Form
Pharmacy Opiate 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

Other Forms and Resources

Ohio Urine Drug Screen Prior Authorization (PA) Request Form
PAC Provider Intake Form
Web Portal Administrator Change Form
PRAF 2.0 and other Pregnancy-Related Forms
ODM Health Insurance Fact Request Form
Request for External Wheelchair Assessment Form

Non-Contracted Practice/Group Information

Ohio Provider Contract Request Form*
Non-Contracted Provider Billing Guidelines

*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 Practices/Groups 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.

pdf Adobe Acrobat Reader is required to view the file(s) above. Download a free version