Specialty Change Forms

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

 

  • Community Choices Waiver Specialty Change Forms

  • Dental Provider Specialty Change Form

  • MDs & DOs Specialty Change Form

  • Personal Care Services (PCS) Specialty Form

  • ROW Specialty/Subspecialty Form

  • School Based Health Center (SBHC) Specialty Form