PA form- new
Molina Healthcare of Michigan
Medicaid, MIChild and Medicare Prior Authorization Request Form
Phone: (888) 898-7969
Medicaid Fax: (800) 594-7404 / Medicare Fax: (888) 295-7665
Radiology, NICU, and Transplant Authorizations: Phone: (855) 714-2415 / Fax: (877) 731-7218
MEMBER INFORMATION
Plan: Molina Medicaid Molina Medicare MIChild Other:
Member Name: DOB: / /
Member ID#: Phone: ( ) -
Service Type: Elective/Routine Expedited/Urgent*
*Definition of Urgent / Expedited service request designation is when the treatment
requested is required to prevent serious deterioration in the member’s health or could
jeopardize the enrollee’s ability to regain maximum function. Requests outside of this
definition should be submitted as routine/non-urgent.
Referral/Service Type Requested
Inpatient
Surgical procedures
ER Admits
SNF
Rehab
LTAC
Outpatient
Surgical Procedure Rehab (PT, OT, & ST)
Diagnostic Procedure Chiropractic
Wound Care Infusion Therapy
Other:
Home Health
DME
In Office
Diagnosis Code & Description:
CPT/HCPC Code & Description:
Number of visits requested: DOS From: / / to / /
Please send clinical notes and any supporting documentation
PROVIDER INFORMATION
Requesting Provider Name:
Facility Providing Service:
Rendering Facility Tax ID #:
Rendering Facility Address:
Contact at Requesting Provider’s office:
Phone Number: ( ) - Fax Number: ( ) -
For Molina Use Only:
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