Forms to Update Existing Provider Information

All forms must be submitted with an original signature by mailing to:

Molina Medicaid Solutions Provider Enrollment Unit

P. O. Box 80159

 Baton Rouge, La. 70898-0159

 

  • Direct Deposit / EFT (Electronic Funds Transfer) Forms

  • EDI Contract and Power of Attorney Forms

  • File Update Form

  • Group Link/Unlink and Working Relationship Form

  • Hospital Specialized Unit Attestation Forms

  • Specialty Change Forms

  • Submitter/Provider Unlinkage Form

  • Disclosure of Ownership Forms