Member Materials and Forms

2026 Molina Medicare Complete Care (HMO D-SNP) - Imperial

Address:		7050 Union Park Center Drive, Suite 600 Midvale, Utah 84047

Fax:		(866) 290-1309

How to Request a Redetermination - Please read this document to understand what you need to do to request an appeal

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

2026 Molina Medicare Complete Care (HMO D-SNP) - Imperial

Redetermination Form - Use this form to request a redetermination (appeal).

You may submit your Redetermination request form here online.

You may also complete the below form and mail or fax.

2026 Molina Medicare Complete Care Plus (HMO D-SNP)

2026 Molina Medicare Complete Care (HMO D-SNP) - Imperial

Complete this form and mail or fax to:

Address:		7050 Union Park Center Drive, Suite 600 Midvale, Utah 84047

Fax:		(866) 290-1309

Direct Member Reimbursement Form - Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.

2026 Molina Medicare Complete Care Plus (HMO D-SNP)