New Facility Request

  If you wish to receive Medicaid reimbursement, you must enroll as a Medicaid Provider through Molina Medicaid Solutions. Enrollment information is available at www.idmedicaid.com. Should you need to seek assistance related to your application process and experience with Molina, please contact Provider Services at 1-866-686-4272.
 
 
 
 
     *FEIN: (nn-nnnnnnn)
   
 
*Business Legal Name:
*Facility Name:
*Address:
Address 2:
*City:
 *County
 *Zip:
  *Contact First Name:
  *Contact Last Name:
  *Contact Email:
  *Contact Phone #: