Molina Prior Authorization Form PDF Details

Navigating the ever-changing health insurance landscape can be a daunting challenge for many providers and their staff. The good news is that Molina Healthcare has created an easy to use Prior Authorization Form available online, to help make the process easier and more convenient than ever before. With this new streamlined form, providers have access to all of the information they need in order to complete authorization requests quickly and accurately. In this post we will explain how you can get started utilizing the Molina Prior Authorization Form so that you are able to effectively utilize quick turnaround times when submitting requested documents.

Form NameMolina Prior Authorization Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesmolina pa form, molina prior auth form, molina prior authorization, molina prior authorization form

Form Preview Example

Molina Healthcare Prior Authorization Request Form

Phone Number: 1-866-449-6849 (Bexar, Harris, Dallas, Jeferson, El Paso & Hidalgo Service Areas) 1-877-319-6826 (CHIP Rural Service Area)

Fax Number: 1-866-420-3639

Member Information

Plan: ☐ Molina Medicaid Molina Medicare TANF Other

Member’s Name: _______________________________________________________ DOB: _________________________________

Member’s ID#: _________________________________________________________ Member Phone #: _______________________

Service Is: ☐ Elective/ Routine ☐ Expedited/Urgent*

*Deinition of expedited/urgent is when the situation where the standard time frame or decision making process (up to 14 days per Molina’s process) could seriously jeopardize the life or health of the enrollee, or could jeopardize the enrollee’s ability to regain maximum function.

Referral/Service Type Requested



Home Health

☐ Surgical procedures

☐ Surgical Procedure


☐ ER Admits

☐ Rehab (PT, OT, & ST)




☐ Diagnostic Procedure


☐ Rehab

☐ Chiropractic




☐ Wound Care

In Oice


☐ Infusion herapy






Diagnosis Code & Description: __________________________________________________________________________________

CPT/HCPC Code & Description: ________________________________________________________________________________

Number of visits requested:____________________________________ Date(s) of Service: __________________________________

Please send clinical notes and any supporting documentation


Requesting Provider Name: _____________________________________________________________________________________

Facility Providing Service: ______________________________________________________________________________________

Contact @ Requesting Provider’s: _________________________________________________________________________________

Phone Number: __________________________________________ Fax Number: _________________________________________

For Molina Use Only:


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If you want to complete this PDF form, make sure you type in the required details in each and every field:

1. The molina prior authorization will require certain information to be inserted. Make sure the next blanks are finalized:

Filling out segment 1 in molina pa form pdf

2. After the last section is done, you need to include the essential specifics in Provider Information, Requesting Provider Name, Facility Providing Service, Contact Requesting Providers, Phone Number Fax Number, and For Molina Use Only in order to proceed to the next step.

Find out how to fill out molina pa form pdf part 2

As for Facility Providing Service and For Molina Use Only, make sure you take another look in this section. These are the most significant fields in this PDF.

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