Moda Health member forms
The full list of forms specific to your plan can be found on your Member Dashboard. Below are some general forms for claims and reimbursement requests.
Pharmacy claims
Verify your pharmacy network on the back of your member ID card to select the correct form(s).
- Prescription drug claim form
- Prescription drug claim form (Uniform Medical Plan (UMP))
Payments and reimbursements
- Direct deposit authorization form
- Autopay EFT authorization agreement (for individual plans)
- Coordination of benefits form
Communication and information sharing
- Protected health information disclosure authorization form
(How to complete this form) - Autorización del miembro para permitir la divulgación de información protegida sobre la salud a otra persona o entidad
- Continuity of care (transition of care) request form
- Formulario de solicitud de continuidad de la atención (transición de la atención)