Molina Healthcare Obstetrical Service Request Form free printable template

OBSTETRICAL Service Request Form IN NETWORK NOTIFICATION/OUT OF NETWORK AUTHORIZATION Fax completed document to: 18664203639 portal: www.molinahealthcare.com Reference#: Start Date: End Date: (Include

How to fill out Molina Healthcare Obstetrical Service Request Form

How to fill out Molina Healthcare Obstetrical Service Request Form

1. Obtain the Molina Healthcare Obstetrical Service Request Form from the Molina Healthcare website or your healthcare provider.
2. Fill in the patient’s personal information, including name, date of birth, and contact details.
3. Provide the patient's insurance information, including policy number and group number.
4. Specify the type of obstetrical services requested, such as prenatal visits or delivery services.
5. Include any relevant medical history or notes that may assist in processing the request.
6. Sign and date the form to certify that the information provided is accurate.
7. Submit the completed form to Molina Healthcare through the designated method (fax, mail, or online submission).

Who needs Molina Healthcare Obstetrical Service Request Form?

1. Expectant mothers seeking obstetrical services covered by Molina Healthcare.
2. Healthcare providers referring patients for obstetrical services under Molina Healthcare.
3. Patients transitioning to Molina Healthcare from another insurance provider requiring service requests.

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What is Molina Healthcare Obstetrical Service Request Form?

The Molina Healthcare Obstetrical Service Request Form is a document used by healthcare providers to request authorization for obstetrical services for patients enrolled in Molina Healthcare.

Who is required to file Molina Healthcare Obstetrical Service Request Form?

Healthcare providers who are treating patients enrolled in Molina Healthcare and require authorization for obstetrical services are required to file this form.

How to fill out Molina Healthcare Obstetrical Service Request Form?

To fill out the Molina Healthcare Obstetrical Service Request Form, providers should accurately complete all required fields with patient information, service details, and any supporting documentation as instructed on the form.

What is the purpose of Molina Healthcare Obstetrical Service Request Form?

The purpose of the Molina Healthcare Obstetrical Service Request Form is to obtain prior authorization for obstetrical services, ensuring that necessary medical procedures are covered under the patient's health plan.

What information must be reported on Molina Healthcare Obstetrical Service Request Form?

The form must report patient demographic information, the specific obstetrical services requested, relevant medical history, and any supporting clinical information that justifies the request.