Forms
If you have any questions, please contact Member Services.
Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Molina Dual Options at:
Molina Healthcare of California
200 Oceangate, Suite 100
Long Beach, CA 90802
How to Request Coverage Determination – To request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy. You may also ask us for a coverage determination by phone at (855) 735-5604, 8:00 a.m - 8:00 p.m., Monday to Friday. TTY/TDD: 711
Mail or fax the form to:
7050 Union Park Center, Suite 600
Midvale, UT 84047
Fax: (866) 290-1309
You can also complete an online secure form by clicking here.
How to Request a Redetermination – Please read this document to understand what you need to do to request an appeal.
Request a Redetermination – You can also download this form and mail or fax it to:
Molina Healthcare
Attn: Grievance and Appeals
P.O. Box 22816
Long Beach, CA 90801-9977
Direct Member Reimbursement Form – Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.
Medicare.gov Complaint Form
- To download a blank copy of the Medicare Complaint Form, click here. You may also access additional information on Medicare’s website at
www.medicare.gov
