Molinalogo

The files below are in PDF format ()

Consent Forms

• Hysterectomy Consent & Patient Form
• Member Consent/Appeal Form
• Member Education Form
• Sterilization Form

Credentialing/Contracting

• Contract Request Form
• Add Provider Request Form (Mini Application)
• Health Delivery Organization (HDO) Form – Facilities
• CMS Ownership Control and Disclosure Form
• W-9

Opioid Policy

• Opioid Policy
• Opioid Attestation Form

Other

• Application for Health Care Coverage
• Dismissal Letter
• Exception to Rule Request
• Notification Form for Change in WISe Services
• PCP Change Request Form
• PCP Change Request Form – Spanish
• Provider Bariatric Program Flyer
• Provider Critical Incident Referral Form
• Provider Dispute Resolution Request Form
• Provider Early Reversal Permission Form

Prior Authorization Request Forms

Pharmacy

• 12.10.99 – Antivirals – HIV Combinations
• 12.10.99.02 – Antivirals – HIV – emtricitabine / tenofovir alafenamide (Descovy®)
• 12.10.99.AA – Antivirals: HIV – rilpivirine (Edurant®)
• 12.10.99.AB – Antivirals: HIV – cabotegravir/rilpivirine (Cabenuva)
• 21.10.40 – Antineoplastics and Adjunctive Therapies - Imidazotetrazines - Oral
• 21.53.40 – TKI Policy
• 23.10.00 – Testosterone
• 27.17.00- GLP1 Agonists
• 39.35.00 – PCSK9
• 40.12.00 – Pulmonary Hypertension (PH) Agents (oral/inhalation)
• 45.30.00 – Cystic Fibrosis
• 52.55.00 – IBS/GI Motility
• 58.12.00- Antidepressants: Serotonin Modulators
• 59.40.00.18 – Vraylar
• 61.40.00.AA- Armodafinil/Modafinil
• 65.20.00.10 – Buprenorphine
• 65.20.00.E5 – Sublocade
• 66.27.00 – Cytokine and CAM
• 67.70.10 – CGRP (Acute)
• 67.70.20 – CGRP (Treatment)
• 68.00.00 – Gout
• 90.05.00.AA – Dermatologics: Acne Products – Isotretinoin
• 90.23.00.AA – Atopic Dermatitis Agents: Crisaborole (Eucrisa™)
• 90.27.30.AA – Dupilumab (Dupixent)
• Brand Generic
• Pharmacy Prior Authorization
• Specialty Medication Request Form
• Synagis^® Prior Authorization

Pre-Service

• Applied Behavior Analysis (ABA) Therapy Prior Authorization Form
• Applied Behavior Analysis (ABA) Level of Support Requirement Form
• Applied Behavior Analysis (ABA) Order Form
• Behavioral Health Admission Notification/Authorization Request Form
• Bariatric Surgery Criteria Pre-Surgical Assessment Form
• Inpatient Rehab, Skilled Nursing Facility, and Long Term Acute Care Request Form
• Prior Authorization Pre-Service Guide and Form Medicaid
• Private Duty Nursing Prior Authorization Request Form

Provider Changes

• Provider Change Form
• Termination Notification Form

Reference/Criteria Guide

• Applied Behavior Analysis (ABA) Provider Utilization Management Guide
• ABA Treatment Prior Authorization FAQs
• BH Provider Prior Authorization Reference Guide
• BMI Index-for-Age Percentile Charts for Children
• Process for Skilled Nursing Facility (SNF) Requests

Referral Forms

• Care Management Referral Form
• Pregnancy Referral Form

Amazon Member Reward Program

Provider Forms

• Amazon Rewards – Provider Form: Children and Adolescents
• Amazon Rewards – Provider Form: Adults

Member Forms

• Amazon Rewards – Program Information
• Amazon Rewards – 30-Month Well-Child Visits
• Amazon Rewards – Childhood Immunizations
• Amazon Rewards – 3-11 Year Well-Care Visits
• Amazon Rewards – ADHD Medication Follow-Up Visit
• Amazon Rewards – Immunizations for Adolescents
• Amazon Rewards – 12-21 Year Well-Care Visits
• Amazon Rewards – Chlamydia Screening
• Amazon Rewards – Prenatal Visit
• Amazon Rewards – Postpartum Visit
• Amazon Rewards – Breast Cancer Screening
• Amazon Rewards – Cervical Cancer Screening
• Amazon Rewards – Diabetes Screening
• Amazon Rewards – Adolescent & Adult Combined Form

 

• Amazon Rewards – Program Information (Spanish)
• Amazon Rewards – 30-Month Well-Child Visits (Spanish)
• Amazon Rewards – Childhood Immunizations (Spanish)
• Amazon Rewards – 3-11 Year Well-Care Visits (Spanish)
• Amazon Rewards – ADHD Medication Follow-Up Visit (Spanish)
• Amazon Rewards – Immunizations for Adolescents (Spanish)
• Amazon Rewards – 12-21 Year Well-Care Visits (Spanish)
• Amazon Rewards – Chlamydia Screening (Spanish)
• Amazon Rewards – Prenatal Visit (Spanish)
• Amazon Rewards – Postpartum Visit (Spanish)
• Amazon Rewards – Breast Cancer Screening (Spanish)
• Amazon Rewards – Cervical Cancer Screening (Spanish)
• Amazon Rewards – Diabetes Screening (Spanish)
• Amazon Rewards – Adolescent & Adult Combined Form (Spanish)

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