Molinalogo

The files below are in PDF format ()

Consent Forms

• Hysterectomy Consent & Patient Form (hca.wa.gov)
• Member Consent/Appeal Form
• Member Education Form
• Sterilization Form (hhs.gov)

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 (irs.gov)

Opioid Policy

To access the opioid policy and opioid attestation form, please visit the Washington Drug Formulary page.

Other

• A-19 State of Washington Form
• Application for Health Care Coverage (hca.wa.gov)
• Dismissal Letter
• Exception to Rule Request
• New Supplier Form
• 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

For pharmacy prior authorization forms, please visit the Washington Drug Formulary page.

• 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
• Medicaid Attestation Form on the Appropriateness of the Qualified Clinical Trial (hca.wa.gov)
• 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 (cdc.gov)
• Molina Healthcare of Washington, Oncology Pathway Solutions FAQs
• Process for Skilled Nursing Facility (SNF) Requests
• Initial Authorization Process - Skilled Nursing Facility
• Washington Health Care Authority Clinical Trials FAQs
• Medicaid Membership Roster Clean-up FAQ, Criteria and Processes

Referral Forms

• Care Management Referral Form
• Pregnancy Referral Form

Member Rewards Program 

• Well-Care Visit Back to School 2023 - Flyer (English)
• Well-Care Visit Back to School 2023 - Flyer (Spanish)
  
  

• Provider Form: Children and Adolescents (English)
• Provider Form: Adults (English)
  
  

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

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

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