Moda Health medical provider contracting request

Interested in joining our provider network? Please complete and submit the new provider network participation request form below.

If you have not already reviewed our nominations panel, please do so before submitting the new provider network participation request form.

Nominations Panel - Oregon
Category	Specialties	County Status
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Counties: All Counties
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Marriage/Family Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Counties: All Counties
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Counties: Baker, Coos, Curry, Douglas, Grant, Gilliam, Harney, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wheeler Closed Counties: Benton, Clackamas, Clatsop, Columbia, Crook, Deschutes, Hood River, Jefferson, Josephine, Klamath, Lane, Linn, Marion, Multnomah, Polk, Jackson, Wallowa, Wasco, Washington, Yamhill
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Counties: Baker, Clatsop, Coos, Curry, Gilliam, Grant, Harney, Jefferson, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wheeler Closed Counties: Benton, Clackamas, Columbia, Crook, Deschutes, Douglas, Hood River, Jackson, Josephine, Klamath, Lane, Linn, Marion, Multnomah, Polk, Wasco, Washington, Yamhill
All Other Specialties	All	Submit for Review
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review

Nominations Panel - Washington
Category	Specialties	County Status
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Counties: Benton Clark Cowlitz Walla Walla
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Marriage/Family Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Counties: Benton Clark Cowlitz Walla Walla
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Counties: Benton, Walla Walla Closed Counties: Clark, Cowlitz
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Counties: Benton, Walla Walla Closed Counties: Clark, Cowlitz
All Other Specialties	All	Submit for Review: Benton Clark Cowlitz Walla Walla
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review: Benton, Walla Walla Closed Counties: Clark, Cowlitz

Nominations Panel - Idaho
Category	Specialties	County Status
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Counties: Ada Adams Canyon Gem Idaho Owyhee Payette Washington
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Family/Marriage Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Counties: Ada Adams Canyon Gem Idaho Owyhee Payette Washington
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Counties: Ada Adams Canyon Gem Idaho Owyhee Payette Washington
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Counties: Ada Adams Canyon Gem Idaho Owyhee Payette Washington
All Other Specialties	All	Submit for Review: Ada Adams Canyon Gem Idaho Owyhee Payette Washington
DME	All	Closed Counties: All Counties
Lab	All	Closed Counties: All Counties
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review: Ada Adams Canyon Gem Idaho Owyhee Payette Washington

*The nominations panel was updated in December 2021 and is reviewed on an annual basis

New provider network participation request form

We will review your information and contact you within 60 days of your submission.

*Specialty:
*Licensed to Practice In (check all that apply): Alaska Oregon Washington Texas None
*County:
*Burrough:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:
Yes No
Medicare PTAN number:
Medicaid Eligible:
Yes No
Medicaid DMAP number:
*Primary Address:
Primary Address Line 2 (optional):
*City:
*State:
*Zip Code:
*Provider contact first/last name:
*Provider email:
*Office/Contracting first/last name:
*Office/Contracting email:
*Phone number:
Fax:
Notes, description of services:

^{*Required field}
Are you a behavioral health provider?
Yes No
Are you currently seeing any Moda members?
Yes No
Are contracted providers referring our members to you?
Yes No
Are you requesting to be a Primary Care Provider (PCP)?
Yes No
If, yes please provide the following information:
Are you a patient centered medical home?
Yes No
Are you able to provide 24/7 coverage for members?
Yes No
Are you able to provide pharmaceutical management to members with chronic conditions?
Yes No

Provider network participating request form