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How to fill out the 888 373 3059 online
This guide provides clear and comprehensive instructions for completing the 888 373 3059 form online. Whether you are a healthcare provider or individual managing a medication request, these steps will ensure you fill out the form accurately and efficiently.
Follow the steps to fill out the form online correctly.
- Press the ‘Get Form’ button to access the document. This will allow you to open the form in your preferred online editor.
- Begin by entering the date of the request. This is important for tracking and processing the authorization.
- Fill out the patient’s date of birth, last name, first name, and Medicaid or MIChild ID. Ensure that all required information is completed clearly.
- Provide the name of the person completing the form, along with the provider’s name and specialty. Include the contact phone number and fax number for the provider.
- Indicate the type of request by checking the appropriate box: Hospital discharge, new request, or reauthorization. If applicable, provide the necessary lab values and other requested information.
- For the drug requested, input the name, strength, dose, quantity, and either the tax ID of the treatment facility or the J code and ICD information, as needed.
- Complete the estimated length of need and diagnosis sections. Additionally, list any previous medications prescribed and their outcomes to provide thorough context.
- Once all fields are completed, review the form for accuracy. Save your changes, and you may have options to download, print, or share the form as needed.
Take action now to complete your 888 373 3059 form online quickly and effectively.
To send claims to Molina of Michigan, you should address them to their designated claims processing center. For the most current address details, please contact them directly at 888 373 3059. Representatives will ensure you have the correct address and can help address any other questions related to submitting claims.
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