Get Molina Referral

Filling out the Molina Referral form accurately is crucial for obtaining necessary healthcare services. This guide provides step-by-step instructions to help you complete the form effectively and efficiently.

Follow the steps to successfully complete the Molina Referral form

1. Press ‘Get Form’ button to access the Molina Referral form in your online editor.
2. Begin by entering the tracking number in the designated field to ensure proper claim tracking.
3. Include the expiration date for the authorization, ensuring this does not lapse during the approval process.
4. Select the appropriate Medi-Cal and Healthy Families product for the service you are requesting.
5. Indicate whether the service request is urgent or non-urgent. Be prepared to explain the urgency if you select 'urgent'.
6. Fill out the member's name, date of birth, and member identification number, ensuring accuracy for identification purposes.
7. Provide the member’s address and phone number in the respective fields to facilitate communication.
8. Specify the referral or service type requested, such as major diagnostic procedures or outpatient services.
9. Complete the requesting provider information section, including the provider's name, address, specialty, and contact information.
10. Fill in the referring to provider information section with the relevant details for the provider you are referring to.
11. Ensure to include the ICD-9 code and description relevant to the service request.
12. Detail the clinical indications for the request, including any pertinent past medical history or treatment information.
13. Attach any relevant medical records or test results to support the request.
14. Provide your signature as the requesting practitioner along with the date of the signature for validation.
15. Review the completed form for accuracy before submission. Once confirmed, save any changes made, and follow up as required.

Complete your Molina Referral form online today to ensure timely processing of healthcare requests.