Contracting

New provider network participation request

Thank you for your interest in joining our select provider network. This page has everything you need to submit your request to become a participating provider with Moda Health.

Upon completing the form, below, your information will be reviewed for contracting consideration. You will be contacted by one of our contract specialists within 30 business days of your submission.

Credentialing requirements

Contracting is contingent on credentialing approval through Moda, or by a delegated credentialing entity. You don't need to begin the credentialing process until your submission has been reviewed. To learn more about credentialing, please visit our Credentialing page.

To get the new participation process started, fill out the short form below. Then, tell us a little about yourself so we can get to know you and your practice better.

For currently contracted providers, please contact your contract specialist for more information on joining additional lines of business and networks.

New provider participation form

*Date:
*NPI #:
*Tax ID:
Taxonomy #:
Medicare #:
Medicaid #:
*Business name:
*Address Line 1:
Address Line 2 (optional):
*City:
*State:
*Zip Code:
*County:
*Contracting contact first/last name:
*Office contact first/last name:
*Contact phone number:
Fax:
*Contracting contact email:
Office contact email:
Additional notes:
*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


Please allow up to 30 business days from your submission date to be contacted by a contract specialist.

If you prefer to submit a print version of the new provider network participation request, just download and complete the fillable form and fax to 503-243-3964 or mail to:

Moda Health
Attn: Contracting
601 SW Second Ave.
Portland, OR 97204

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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.

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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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