Get Molina Contract Request Form

Filling out the Molina Contract Request Form online is an important step in ensuring proper contract and credentialing processes. This guide will walk you through each section and field of the form to help you complete it accurately and efficiently.

Follow the steps to fill out the Molina Contract Request Form online.

1. Press the ‘Get Form’ button to access the contract request form and open it in your chosen editor.
2. Enter your email address in the designated field to ensure accurate communication.
3. Fill in the requestor's name and phone number, as these details are essential for follow-up.
4. If you are adding a provider to an existing group, check the appropriate box.
5. Provide the provider's name, group name, and specialty in the specified fields.
6. Input the Tax ID number for the provider to ensure proper identification.
7. Fill in the physical address where members will be seen and the relevant mailing address.
8. Complete the city, state, and zip code for both addresses.
9. Enter the office phone and fax numbers for the provider and the group.
10. Provide the individual TPI (Texas Provider Identifier) and group TPI numbers, noting that attestation is required.
11. Include the individual NPI (National Provider Identifier) and group NPI numbers, ensuring they are attested.
12. Fill in the individual and group Medicare numbers, where applicable.
13. If the mailing address for the contract packet is different from above, provide that information.
14. Specify the date you are requesting the contract.
15. Review all entries for accuracy to prevent processing delays.
16. Once completed, save your changes, download, print, or share the form as necessary.

Complete your documents online today to ensure a smooth contracting process.