Molinalogo

Prior Auth LookUp Tool

Prior Authorization Requests

• Notice of Decision, Behaviorally Complex Care Program Form 
• Behavioral Health Prior Authorization Request Form and Instructions
• Prior Authorization Request Form and Instructions
• 278 – Service Request for Review and Response

Prior Authorization Reconsiderations and Appeals

• Appeal Representative Authorization

• ECHO Health Inc EFT Registration
• COVID-19 Billing Guide 
• Provider Billing Guide 

• Pharmacy Prior Authorization Request Form
  
  

 Women’s Health Services

• Provider Information Update Form
• Request to Change Primary Care Provider
• Request to Change Primary Care Provider (Spanish)

• Hysterectomy Acknowledgement Form 
• Consent for Sterilization Form - HHS 687
• Instructions for Completing Consent for Sterilization Form - HHS 687
• Provider Roster template