SERVICE REQUEST FORM

Molina Healthcare of Washington, Inc. Reference #______

PO Box 1469

Bothell, WA98041-1469

Prior Authorizations (UM) Phone: (425) 424-1109, (800) 869-7185

Fax: (800) 767-7188

Prior Authorizations all WMIP including Mental Health phone: (800)936-9647

Fax: (800) 814-2535

Mental HealthPhone: (800) 695-2115

Fax: (800) 334-8979

Member Information WMIP  HO  SCHIP  BH  BH+  (check line of business)

Member Name (Last, First) / Date of Birth / Member I.D.
Address: (No., Street, City, State, Zip) / Phone Number:
( )
SERVICE IS:
MEDICALLY EMERGENT* (Needed immediately) ELECTIVE (within 48 hours)

Referral/Service Type Requested

1

CONFIDENTIALITY NOTICE

The documents accompanying this telecopy transmission contain confidential information belonging to the sender which is privileged. The information is intended only for the

use of the individual(s) or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this telecopy in error, please immediately notify us via telephone at the number above or return original documents to address listed above. Thank you

SERVICE REQUEST FORM

Specialist Consult/Treatment/Follow-Up Care
Inpatient Admission
Diagnostic Procedure / Home Health/Home Infusion
Hospice
DME
Other______ / Surgical Procedure IP/OP
Requested LOS______
Facility______
Date/Time of Service______

1

CONFIDENTIALITY NOTICE

The documents accompanying this telecopy transmission contain confidential information belonging to the sender which is privileged. The information is intended only for the

use of the individual(s) or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this telecopy in error, please immediately notify us via telephone at the number above or return original documents to address listed above. Thank you

SERVICE REQUEST FORM

Requesting Provider Information
Requesting Provider Name: (Last, First) / Specialty: / Phone Number:
( )
Address: (No., Street, City, State, Zip) / Fax Number:
( )

Referred to Provider Information

Referred to Provider Name: (Physician, Facility, Agency) / Specialty: / Phone Number
( )
Address: (No., Street, City, State, Zip) / Fax Number
( )
Procedure Information
ICD-9 Code/Description: / CPT Code/Description: / HCPC/Description:
Clinical Indications for Request: (may attach clinical or progress notes):
Requesting Provider Signature:Date Member Seen:PCP Name:
MOLINA USE ONLY
Authorization status
Approved
______
______ / Pending (reason)______
______
Denied (reason)______
Comments______
Comments:
Medical Director:Medical Director Signature: Date:

1

CONFIDENTIALITY NOTICE

The documents accompanying this telecopy transmission contain confidential information belonging to the sender which is privileged. The information is intended only for the

use of the individual(s) or entity named above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this telecopied information is strictly prohibited. If you have received this telecopy in error, please immediately notify us via telephone at the number above or return original documents to address listed above. Thank you