Molina healthcare health delivery organization application 2011 form-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, 'Organization Information.' Fill in the legal name of your organization as listed with the IRS, and provide any applicable DBA names. Ensure all contact details are accurate.
3. Proceed to Section 2, 'Physical Location Information.' Here, specify each practice location's details, including Medicare certification status and accessibility options. Use our platform’s text fields to input this information seamlessly.
4. In Section 3, indicate your primary contracted specialties by checking all relevant boxes. If necessary, attach additional sheets for multiple locations.
5. Complete Section 4 regarding current insurance coverage. Attach a copy of your liability insurance face-sheet using our document upload feature.
6. For Section 5 on accreditation/certification, ensure you attach copies of relevant certificates as required.
7. Finally, review the attestation section in Section 6 carefully before signing. Ensure all information is complete and accurate before submission.

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