Molinalogo

Here you can find all your provider forms in one place. If you have questions or suggestions, please contact us. 

Claims Forms

 Participating Provider Claim Dispute Form

Provider Network Forms

 Add a Practitioner Form
 Primary Care Provider Panel Change Request
 Provider Termination Request Form
 Practice Demographic Form
 Group/Provider Additional Address Form
 Provider Tax ID Change Request Form
 Provider Information Change Form
 Registration of Locum Tenens Physician Form

Non-Participating Provider Forms

 Waiver of Liability Form
 Level One Provider Appeal Form
 Registration for Non-Participating Providers

Utilization Management Forms

 Medicare PA Guide
 Medicare PA Form
 Medicare BH PA Form
 Medicare Pharmacy PA Form

Behavioral Health Forms

 Psychological & Neuropsychological Testing Request
 Psychological and Neuropsychological Assessment Supplemental Form

Pharmacy Forms

Passport Advantage

 2022 Rx Mail Order Form
 2022 Redetermination Form

Passport Medicare Choice Care (HMO)

 2022 Coverage Determination Request Form
 2022 Rx Mail Order Form
 2022 Redetermination Form