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Molina Medicare |
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Forms |
The links below are in PDF format ( ),
please click on them to download printable copies: |
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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 please reference the CMS Appointment of Representation form (Form CMS-1696). You and your appointed representative must complete this form and mail it to Molina options plus at
Molina Medicare
7050 Union Park Center, Suite 200
Midvale, UT 84047 |
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*Paper copies of information posted
on our web site are available upon request. |
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| Molina Medicare is an organization with a
Medicare contract. This contract is renewed annually,
and coverage beyond the end of the contract year is not
guaranteed. |
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