Get Mycare Ohio Uniform Authorization Request Form - Molina Healthcare

This guide provides clear and supportive instructions on how to effectively fill out the MyCare Ohio Uniform Authorization Request Form from Molina Healthcare online. Following these steps will help ensure your request is accurate and complete.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to download the MyCare Ohio Uniform Authorization Request Form, making it accessible for editing.
2. Begin by filling in the top section of the form. Include the member's name, birth date, and ID, ensuring that this information matches the data in the plan's system. Additionally, enter the date the authorization is requested.
3. Input your agency's name, NPI number, phone number, and fax number in the designated fields to identify the requestor.
4. Specify the service date span requested. Note that this can be any necessary period, but may not be approved as submitted.
5. Provide the primary ICD-9 code for skilled services. If unskilled services are needed, include the diagnosis in this section.
6. Check the appropriate documents you are including with the form, such as the OASIS/Assessments or Plan of Care/Orders.
7. Indicate the requested services by filling out the appropriate sections based on the type of care needed: Medicare Services, Medicaid State Plan Home Health Services, PDN Services, or Waiver Services.
8. For Medicare services requested, ensure that all eligibility requirements are met and the number of visits per week is reflected accurately.
9. For Medicaid services, detail the required visits or hours per week in the respective fields.
10. Complete the Provider Comments section to clarify any complex requests and include the agency contact's title, department, phone number, and extension.
11. Confirm that all information is filled out correctly, making any necessary edits, and then proceed to save your changes.
12. Finally, you can download, print, or share the completed form as needed.

Complete your documents online today to ensure a seamless authorization request process.