Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access and open the Molina Prior Authorization Form in your preferred PDF editor.
2. Enter the date of request in the designated field.
3. Fill in the patient's date of birth (DOB) accurately.
4. Provide the patient's last name and first name in the appropriate fields.
5. Input the 10-digit patient ID to identify the patient in the system.
6. Include the name of the person completing the form in the relevant section.
7. Indicate the provider's name and specialty to ensure proper categorization.
8. Complete the provider's address to facilitate communication.
9. Fill in the provider's phone number, including the area code.
10. Provide the provider's fax number with the area code.
11. Select the appropriate option for hospital discharge, new request, or reauthorization.
12. If applicable, provide the required progress notes for specialty injectables or non-formulary medications.
13. For specific medications such as cholesterol lowering drugs, ensure to include recent lipid panel results.
14. For diabetes treatments, attach the A1c report drawn within the last 90 days.
15. If requesting proton pump inhibitors with BID dosing, include the endoscopy report.
16. Attach a medication log and progress notes for pain management requests.
17. Specify the drug requested, including one drug per form.
18. Indicate the name, strength, dose, quantity, and tax ID of the treatment facility.
19. Provide the number of units required and if applicable, include the J code.
20. Fill in the relevant ICD diagnosis code.
21. Name the treatment facility where the prescribed medication will be obtained.
22. Estimate the length of need for the requested medication.
23. Detail previous medications prescribed and their outcomes.
24. Once all information is complete, ensure to save changes, download, print, or share the form as needed.

Begin completing your Molina Prior Authorization Form online for a smooth submission process.