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Molina prior authorization form

Molina authorization form 2025

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The document is a Molina Healthcare/Molina Medicare Prior Authorization Request Form, used to request approval for various medical services including inpatient, outpatient, and home health care. It requires member information, service type details, ICD-9 and CPT/HCPC codes, and supporting documentation. The form distinguishes between routine and urgent requests based on the member's health needs.

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Click ‘Get Form’ to open the Molina Authorization Form in our editor.
Begin by filling out the MEMBER INFORMATION section. Enter your Plan type (Molina Medicaid or Molina Medicare), Member Name, Member ID#, and Date of Birth. Ensure that your contact phone number is accurate.
Specify the Service Type by selecting either Elective/Routine or Other. If urgent, check the Expedited/Urgent box and provide a brief explanation if necessary.
In the Referral/Service Type Requested section, select all applicable options such as Inpatient, Outpatient, Home Health, etc., and provide relevant codes (ICD-9 and CPT/HCPC) along with the number of visits requested.
Complete the PROVIDER INFORMATION section by entering the Requesting Provider Name, Facility Providing Service, Contact at Requesting Provider’s office, and their phone number.
Finally, ensure you attach any clinical notes and supporting documentation before submitting your form.

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Versions	Form popularity	Fillable & printable
2016	4.7 Satisfied (35 Votes)
2014	4.8 Satisfied (190 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a medical authorization form?

A HIPAA authorization form gives covered entities permission to use protected health information for purposes other than treatment, payment, or health care operations. Continue reading to find out when authorization to disclose health information is needed.

What is the phone number for Molina prior authorization?

California: 1(866) 508-6445. Florida: 1(866) 236-8531. Illinois: 1(855) 365-8112.

Does Molina require prior authorization?

0:26 4:27 Some durable medical equipment like hospital beds or electric wheelchairs. For the best outcomes theMoreSome durable medical equipment like hospital beds or electric wheelchairs. For the best outcomes the prior authorization. Process should start with your provider.

What is a drug authorization form?

This is called a prior authorization. This helps make sure the drug or service is safe and necessary for your care. Your doctor or provider usually makes this request for you. Without this pre-approval, Blue Shield may not help pay for your medication or medical service, and you will have to pay out of pocket.

What is treatment authorization?

It designates that treatment covered by the bill has been authorized by the payer.

molina prior auth form

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What is a treatment authorization form?

Providers can use this form to request authorization for outpatient services, out-of-area authorized referrals and durable medical equipment requests.

What is the purpose of an authorization form?

What is an Authorization Form? An authorization form is a document that is duly endorsed by an individual or organisation which grants permission to another individual or organisation to proceed with certain actions. It is often used to grant permission to carry out a specific action for a fixed period of time.