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 MyCare Ohio at:
Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020
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.
Mail or fax the form to:
Molina Healthcare of Ohio, Inc.
P.O. Box 349020
Columbus, OH 43234-9020
Fax: (614) 781-1474
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
Fax: (614) 781-1474
You can also complete an online secure form by clicking here.
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
*Materials are also available in printed and alternative formats, such as large print, audio, or Braille.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.