Get Thank You For Your Interest In Becoming A Molina Healthcare Provider

This guide provides clear, step-by-step instructions for filling out the Thank You For Your Interest In Becoming A Molina Healthcare Provider form online. Completing this form accurately is essential for the contract and credentialing process.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by selecting the type of provider you are. This includes options such as Individual, Group, Nursing Facility, and more. Select the appropriate box that corresponds to your provider type.
3. If you are adding a provider to an existing group, be sure to check the appropriate box. Along with this request, submit the current group roster.
4. Fill in the requestor's name, phone number, email address, and fax number. This information is vital for any correspondence regarding your application.
5. Enter the provider's name and group name if applicable. This ensures that the contract is correctly associated with the intended individuals and entities.
6. Provide the business/service address, mailing address, city, state, and zip code for the provider. Accurate address information is crucial for effective communication.
7. Complete the contact information section, including office phone, contact phone, office fax, contact fax, office email, and contact email. This helps Molina Healthcare reach out for any queries.
8. Specify the specialty and taxonomy related to the provider. This information aids in categorizing and processing the application correctly.
9. Fill in the Tax ID and Bill Type fields. Select the appropriate options such as CMS1500, UB04, or Both.
10. Include the individual and group NPI/API numbers and individual/group TPI, if applicable. Also, provide the Medicare details as these are required for contracting.
11. If there are any additional locations, please attach a roster of those locations with your application.
12. Indicate if you would prefer to receive the contract via email or specify another method. Ensure to fill in the DADS contract number if you have one.
13. Review the completed form for accuracy and clarity before submission.
14. Once completed, submit the form along with a current W-9 to the provided fax number or email address. After submission, allow 3-5 business days for the contract packet to be mailed.

Complete your documents online to ensure a smooth processing experience.