Molinalogo

Healthcare Services Forms: 
Health Education Referral Form  
Disease Management/Case Management Referral Form
Delivery Notification Form
Neonatal Transfer Form
Pregnancy Notification Report  
Abortion Statement  ***
SBIRT Integrated Screening Tool

Prior Authorization Forms: 
Universal Prior Authorization Form BabyNet
BH Prior Authorization-Outpatient Treatment-Higher Level of Care Form  
Prior Authorization Request Form  
Prior Authorization Medications Form
Universal Synagis Prior Authorization Form ***

Provider Network/Credentialing Forms: 
Credentialing Checklist
Credentialing Packet
Practice Demographics Form  
Provider Change Form  
Primary Care Provider Change Request Form
Contract Request Form
Facility HDO Form
Attachment C Provider Roster
SCDHHS Ownership Form  ***
Non Medicaid Enrolled Ownership Disclosure Form

Claims Forms: 
Provider Recovery Reversal Permission Form

Provider Resources:
POD Data Verification Fax
January 2022 Blank Check Issue Provider Fax
February 2022 Well Visit Provider Incentive Fax
July 2022 ProviderNet Outage Fax
July 2022 Interoperability Fax
August 2022 ProviderNet Outage Fax
August 2022 Paper Claims Fax
August 2022 HealthMap General Provider Notice Fax
October 2022 New Moms Fax
October 2022 Provider Satisfaction Survey
November 2022 Notice of Change Incorrect Claims Fax
November 2022 ProviderNet Shutdown Fax
December 2022 Portal Sunset Fax
January 2023 Cold and Flu Fax
February 2023 Pharmacy Timeliness PA Changes Fax
March 2023 Fax Size Submission
June 2023 Progeny Provider Notification
July 2023 Nursing Facility Admissions Update
August 2023 Advanced Imaging Fax
November 2023 Fall Updates fax

*** SCDHHS STATE MANDATED REQUIRED FORMS FOR SUBMISSION