Molinalogo

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Claims
 Provider Dispute Resolution Request Form 

Credentialing
 CAQH Provider Data Portal
 HIV and AIDS Specialist Form 
 Provider Data Form
 Supervising Physician Provider Verification Form

Prior Authorizations
 Prior Authorization Code Look-up Tool
 Prior Authorization 2024 Form

Additional Authorization Forms
 Applied Behavior Analysis Referral Form
 Behavioral Health Therapy Prior Authorization Form (Autism)
 Community-Based Adult Services (CBAS) Request Form
 Continuity of Care Form
 DHCS 6013A Medical Review/Prolonged Care Assessment Form
 HS-231 Certification for Special Treatment Program Services Form
 Molina ICF/DD Authorization Request Form

Referral Forms
 Care Management Referral Form
 Community Health Worker Referral Form

Community Supports
 CS Asthma Remediation Referral Form
 CS Community Transition Services Referral Form
 CS Day Habilitation Programs Referral Form
 CS Environmental Accessibility Adaptations – Home Modification Physician Form
 CS Environmental Accessibility Adaptations – Home Modification Referral Form
 CS Housing Deposits Referral Form
 CS Housing Tenancy and Sustaining Referral Form
 CS Housing Transition Navigation Referral Form
 CS Medically Tailored Meals Referral Form
 CS Personal Care and Homemaker Services Referral Form
 CS Recuperative Care Referral Form
 CS Respite Services – Home Referral Form
 CS Short-Term Post-Hospitalization Housing Referral Form
 CS Transition to Assisted Living Facilities or Residential Care Facilities Referral Form

 Dental Coordination Referral Form
 Doula Services Referral Form
 Enhanced Care Management Member Referral Form
 Housing Specialist Referral Form
 Pregnancy Referral Form

Transportation
 Physician Certification Statement

Pharmacy
 Medical Benefit (HCPCS/J-Code) Drug Prior Authorization Form
 Prescription Drug Prior Authorization Request Form

Other Forms and Resources
 ICE Roster Template
 Provider Information Data Form

Medi-Cal Non-Covered Services
 Member Grievance Form (English)
 Member Grievance Form (Spanish)
 Member Grievance Form (Arabic)
 Member Grievance Form (Chinese)
 Member Grievance Form (Hmong)
 Member Grievance Form (Russian)
 Member Grievance Form (Vietnamese)
 Member Grievance Form (Tagalog)
 Member Grievance Form (Farsi)
 Allowed In-Office Lab Test List, effective 5-15-2018

Health Education Forms
 Health Education Referral Form

Health Management Services Flyer (for Members only)
 English |  Spanish |  Arabic |  Vietnamese |  Chinese |  Hmong |  Armenian |  Korean |  Russian |  Tagalog

 Health Education Services Provider Resources Flyer (for Providers only)

Cultural & Linguistic Services Forms
Member Resources for Cultural and Linguistic Services ( English |  Spanish |  Arabic)
Provider Resources for Cultural and Linguistic Services ( English)

Smoking Cessation Resources
 ACOG Guidelines – Smoking Cessation During Pregnancy
 CA Quits Toolkit - A Guide to Integrate Tobacco Treatment into Health Systems
 Support Groups and Classes

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