You can submit this form via fax at (800) 961-5160 or call Molina Marketplace at (855) 322-4079 for further assistance. Alternatively, you may submit the form to your healthcare provider, who can then forward it to Molina for you. Always ensure that you keep a copy of the submitted form for your records.

Important submissions dates for this form are to be determined for the years 2024 and 2025 depending on patient needs and changes in healthcare regulations. Ensure you keep track of updates through your healthcare provider or Molina’s announcements. Always check for new submission guidelines as they may come into effect yearly.

The purpose of the Molina Patient Information Authorization Form is to enable patients to request necessary medication approvals efficiently. It serves as a formal request to insurance companies, detailing the patient’s medical history and current treatment needs. This form ensures that all required information is collected to facilitate the authorization process and prior approvals.

• 1. Patient Name: Full name of the patient.
• 2. DOB: Date of birth of the patient.
• 3. Patient ID #: Unique identifier for the patient.
• 4. Sex: Gender of the patient.
• 5. Medication Allergies: List of any known allergies to medications.
• 6. Prescriber Information: Details of the prescriber, including name and NPI.
• 7. Medication Requested: Information about the medication the patient needs.
• 8. Diagnosis: Details regarding the patient's medical condition.
• 9. Previous Medications: List of past medications related to the current request.
• 10. Provider Signature: Signature of the healthcare provider.

Failure to submit this form can result in delays in obtaining necessary medication treatments. It is crucial to ensure that all information is accurately provided to avoid any complications in the authorization process.

• Delayed Medication Access: Without timely submission, patients may face delays in receiving their prescribed medications.
• Increased Administrative Burden: Errors or omissions can lead to increased workload for healthcare providers.
• Insurance Denials: Incomplete forms may result in insurance companies denying coverage for medications.

• 1. When starting a new medication: Patients should fill out this form if they are prescribed a new medication that needs insurance approval.
• 2. If previously denied medication coverage: Utilize this form if you have faced denial for medication coverage in the past.
• 3. For costly treatments: Submit this form for medications that are high-cost and may require detailed justification for approval.