Get Washington Molina Marketplace Appeal Request Form. Washington Molina Marketplace Appeal Request Form

Filling out the Washington Molina Marketplace Appeal Request Form is an essential step if you wish to appeal a decision made by Molina Healthcare. This guide provides clear and supportive instructions to help you navigate the form efficiently.

Follow the steps to complete your appeal request form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date of the appeal submission in the designated space at the top of the form.
3. Provide your member ID number accurately in the specified field to ensure proper identification.
4. Fill in your last name, followed by your first name to establish your identity.
5. Complete your current address, including the city, state, and zip code, to ensure that correspondence reaches you.
6. Enter your phone number in the appropriate field for any follow-up communication.
7. Provide the name of your healthcare provider in the field designated for the doctor’s name.
8. Describe the specific issues you are appealing in a detailed manner within the provided space.
9. Ensure to mail all supporting documentation regarding your appeal to the address specified on the form.
10. If someone else is filing the appeal on your behalf, provide your written permission in the Authorized Representative Permission Statement section, including their name.
11. Sign and date the form to officially submit your appeal request.
12. Once completed, you can save changes, download, print, or share the form as needed.

Complete your appeal request form online today and ensure your voice is heard.