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New provider network participating request form

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.

Check the panel now

Nominations Panel
Oregon county Open specialties Closed specialties
Clackamas, Multnomah and Washington Behavioral health (if not listed as closed), PCP, cardiology, dermatology, OB/GYN, orthopedics, radiology, gastroenterology, oncology, and rheumatology Acupuncture, chiropractic, massage therapy, ophthalmology, licensed professional counselor, licensed clinical social worker, licensed marriage and family therapist, psychologists, DME and ALL other specialties which are not listed as open
Benton, Lane, Marion, Polk, Jackson and Yamhill Behavioral health, PCP, cardiology, dermatology, OB/GYN, orthopedics, radiology, gastroenterology, oncology, rheumatology, infectious diseases, midwifery, physiatry/rehab medicine, speech therapy and vascular surgery Acupuncture, chiropractic, massage therapy, Optometry, ophthalmology, DME and ALL other specialties which are not listed as open
Columbia, Coos, Deschutes, Douglas, Josephine, Klamath, Linn and Umatilla Behavioral health, PCP, cardiology, dermatology, OB/GYN, orthopedics, radiology, gastroenterology, oncology, rheumatology and ALL other specialty types which are not listed as closed Chiropractic, occupational therapy, optometry, ophthalmology, orthopedic surgery, otolaryngology and physical therapy
Baker, Clatsop, Crook, Curry, Grant, Gilliam, Harney, Hood River, Jefferson, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Union, Wallowa, Wasco and Wheeler All specialty types (with the exception of DME providers) DME

*We update this nominations panel annually. We last updated it in July 2018.

New provider network participation request form

*Specialty:
*County:
*Business/Provider name:
*Tax ID:
*NPI #:
*Address Line 1:
Address Line 2 (optional):
*City:
*State:
*Zip Code:
*Contracting contact first/last name:
*Office contact first/last name:
*Contracting contact email:
*Contact phone number:
Fax:
Office contact email:
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

What types of services do you provide?
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


We will review your information and contact you within 30 business days of your submission.

You can also submit a print version of this new provider network participation request form.

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Hello.

We have exciting news to share. ODS is changing its name to Moda Health.

Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.

Together, we can be more, be better.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

Hello.

Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:

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