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Molina prior authorization form 2017 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM. Plan/ Medical Group Name: Molina Healthcare of California. Plan/Medical Group Phone#:. 12/13/2016http://author.molinahealthcare.com/providers/fl/medicaid/forms/Pages/fuf.aspx.
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How to fill out molina prior authorization form
How to fill out molina prior authorization form
01
Read the instructions on the Molina Prior Authorization form carefully.
02
Fill out your personal information including name, address, and contact details.
03
Provide your Molina member ID number and the name of the primary insured person.
04
Indicate the date of service for which you are seeking prior authorization.
05
Specify the medical procedure or service that requires prior authorization.
06
Include the name and contact information of the healthcare provider who recommended the procedure.
07
Attach any necessary supporting documents such as medical records, test results, or notes from the healthcare provider.
08
Sign and date the form to certify the accuracy of the information provided.
09
Submit the completed Molina Prior Authorization form to the designated address or fax number as indicated on the form.
10
Wait for a response from Molina regarding the prior authorization request.
Who needs molina prior authorization form?
01
Individuals who are covered under a Molina health insurance plan and require a medical procedure or service that requires prior authorization.
02
Healthcare providers who want to request prior authorization for their patients covered under a Molina health insurance plan.
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