Molina Healthcare Service Request Form

The following information applies to Los Angeles County only.

Molina Healthcare requires that its directly contracting primary care physicians (PCPs), staff model physicians and directly contracting medical groups complete a Service Request form (PDF) by following these instructions:

• Do not schedule non-emergency services until authorization is given
• This form is to be completed by the requesting provider
• CONTROL NUMBER - For Molina use only; do not write in this space
• EXPIRATION DATE - For Molina use only; do not write in this space
• DATE - Enter the date the form was completed by the requesting provider
• PATIENT INFORMATION - Complete all lines, including member name, date of birth, member identification number, address, and telephone number
• SERVICE IS - Describe level of medical need. Check one: emergency (needed immediately), urgent (needed within 24 hours), elective (routine). Emergency services which meet Title 22 definition for an emergency do not require prior authorization
• SERVICE TYPE - Check one or more boxes that best describe the request. Use Other for unlisted services and the Comments line to describe the service requested (for example, outpatient physical therapy, home intravenous (IV) therapy, prescription medication)
• "REQUESTING" PROVIDER INFORMATION - Complete all lines, including requesting provider name, specialty, address, and telephone and fax numbers
• "REFERRED TO" PROVIDER INFORMATION - Complete all lines, including provider name, specialty, address, and telephone and fax numbers (if referring to non-participating provider, note the reason)
• PROCEDURE INFORMATION - Use accurate ICD-10 and HCPCS codes. Include narrative description if needed. Request for service must include the signature of the requesting provider. Enter the date of service
• INDICATIONS - Must be completed. Include medical history, test results, physical findings, all relevant medical records, and other relevant information. Requests are not processed if blank
• MOLINA USE ONLY - Do not write in this space
• When the form has been processed and returned to the requesting provider, distribute as indicated:
  • White - Molina corporate office
  • Pink - Referring provider
  • Blue - Referred to provider
  • Yellow - Member

  Note that payment for these services by Molina is contingent on the member's eligibility for plan coverage on the date of service.