Are you an insured Michigan resident looking for a prior authorization form to cover the cost of your prescription? If so, look no further! This blog post will provide all the information you need to submit a Molina Prior Authorization (PA) Form. We'll walk you through what types of drugs and services require a PA Form, how to locate it, how to fill it out correctly, and how long it usually takes for approval. With this guide in hand, you should have no trouble getting the medications that are necessary for your health and well-being. So let's get started!
| Question | Answer |
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| Form Name | Michigan Molina Prior Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | molina medicaid prior authorization form michigan, molina prior authorization form michigan, molina prior authorization form pdf, molina prior authorization form for medication |
Molina Healthcare of Michigan Prior Authorization Request Form
Phone Number: (888)
Medicaid Fax Number: (800)
Medicare Fax: (888)
Member I nformat ion
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Molina Medicaid |
Member Name:
Molina MI Child
Molina Medicare
DOB:
Other:
Member I D# : |
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Member Phone # : |
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Service I s:
Elective/ Routine
Expedited/ Urgent *
*Definition of Urgent / Expedited service request designation is w hen the treat ment requested is required to prevent serious deterioration in the member’s health or could jeopardize the member’s ability to regain maximum function. Requests outside of this definition should be submitted as routine/ non- urgent.
Referral/ Service Type Request ed
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Referred To Provider/ Facility Name & Tax I D# : _____ |
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Referred To Address & Phone# : |
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Diagnosis Code & Description: |
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CPT/ HCPCS Code & Description: |
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Number of visits requested: |
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Date(s) of Service: |
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Please send clinical not es and any support ing document at ion |
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Provider I nformat ion |
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Requesting Provider Name and Address: |
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Contact @ Requesting Provider’s: |
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Phone Number: ( |
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Fax Number: ( |
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For Molina Use Only: |
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2013 MI Molina Healthcare/ Molina Medicare PA GUI DE 5/ 8/ 13