Frequently Used Forms
Appeals
Grievance Consent Form Provider Appeal Form
Behavioral Health
Behavioral Health Prior Authorization Form Combined MCE Behavioral Health Provider Primary Care Provider Communication Form
Contracting & Provider Network
Provider Contract Request Form Wisconsin W9 Provider Roster Template Provider Information Update Form
Credentialing
Molina Healthcare of WI- Practitioner Application
Molina Healthcare Health Delivery Organization (HDO) application
Molina Healthcare of WI CAQH Credentialing Checklist
My Choice Wisconsin by Molina Healthcare Attestation Form
Claims and Adjustments
Overpayment Form Prior Authorization
Updated 10/1/24: 2024 PA Guide Request Form
Q4 2024 Medicaid Prior Authorization Code Matrix
Q3 2024 Medicaid Prior Authorization Code Matrix
Q2 2024 Medicaid Prior Authorization Code Changes
Q1 2024 Medicaid Prior Authorization Code Changes
2023 PA Guide Request Form
Q4 2023 Medicaid Prior Authorization Code Changes
Q3 2023 Medicaid Prior Authorization Code Changes
Q3 2023 Medicaid Prior Authorization Code Matrix
Q2 2023 Medicaid Prior Authorization Code Changes
Q2 2023 Medicaid Prior Authorization Code Matrix
Q1 2023 Medicaid Prior Authorization Code Changes
Q1 2023 Medicaid Prior Authorization Code Matrix
2022 PA Guide Request Form
Q1 2023 Medicaid Prior Authorization Code Changes
Q4 2022 Medicaid Prior Authorization Code Matrix
Q4 2022 Medicaid Prior Authorization Code Changes
Q3 2022 Medicaid Prior Authorization Code Matrix
Q3 2022 Medicaid Prior Authorization Code Changes
PCW PA Request Form – Medicaid
Referral and Other Health Care Forms
Peer to Peer and Provider Reconsideration Form Hospice Benefit Election Form National Diabetes Prevention Program Referral Authorization for Use and Disclosure of PHI Authorization for Use and Disclosure of PHI (Spanish) PNCC Provider Notification Form Case Management Referral Form Clinical Care Coordination Referral Form Pregnancy Notification Form