MedicaidDonationForm

In-Kind Donation Form

This form is used to request that Molina Healthcare of South Carolina sponsor your:

* Denotes Required Fields.

*Contact Name:

*Email:

*Phone Number:

*Organization’s name:

Website:

*Describe the organization’s mission:

*List the counties the organization serves:

*Describe the audience and the population(s) it serves:

*Describe the organization’s donation needs (please include the date needed by and quantities, if applicable):

*Describe what the in-kind donations will be used for. Please be specific:

*Describe any logo or marketing requirements and deadlines:

*Note any special needs or requests not mentioned above:

Volunteer Opportunities

Through Helping Hands, Molina Healthcare’s employee volunteer program, Molina employees are encouraged to give back to the community. Helping Hands offers employees paid-time off to do direct volunteer work with local organizations such as homeless shelters, after-school programs and food pantries. Please describe any potential volunteer opportunities with your organization:

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Please complete required questions and resubmit

Please enter your email address in name@email.com format.

Please enter a 10 digit telephone number

Please enter a valid Zip code

Please submit any additional documents to SCSponsorshipRequest@MolinaHealthcare.com. In approximately 4 weeks, you will receive a reply to your request.

You may have to pay for services that are not covered. You may also have to pay for services from providers not part of our network. If the services were an emergency, you don’t have to pay. If you need help, call Member Services.

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In-Kind Donation Form

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