Behavioral Health Service Request Form - Molina 2026

1. Click ‘Get Form’ to open the Behavioral Health Service Request Form - Molina in the editor.
2. Begin by entering the member's name, ID, Medicaid ID, date of birth, and phone number in the designated fields. Ensure accuracy for seamless processing.
3. Fill in the facility name and discharge date. This information is crucial for tracking the member's care post-discharge.
4. Provide the facility contact name, phone number, and fax number. This allows for effective communication between parties involved.
5. For South Carolina Department of Mental Health staff, enter the date of appointment post-discharge and provider details. Indicate whether the member kept their scheduled appointment by circling 'Yes' or 'No'.
6. If applicable, note the rescheduled appointment date if the member did not keep their original appointment.
7. Finally, ensure all fields are completed accurately before submitting. Use our platform’s features to review and sign if necessary.

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