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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 Specialties

Clackamas
Multnomah
Washington

Primary Care: Open
Behavioral Health: Closed
Alternative Care: Closed
DME: Closed
Specialist: Closed
Other: Submit for review

Exception: Open to BH specializing in child/adolescent services

Benton
Lane
Marion
Polk
Jackson
Yamhill

Primary Care: Open
Behavioral Health: Open
Alternative Care: Closed
DME: Closed
Specialist: Open to Neonatology, Oncology, Sports Medicine, Vascular Surgery only

Other: Submit for review

Columbia
Coos
Deschutes
Josephine
Klamath
Linn
Umatilla

Primary Care: Open
Behavioral Health: Open
Alternative Care: Closed
DME: Closed
Specialist: Submit for review

Other: Submit for review

Baker
Clatsop
Crook
Curry
Grant
Gilliam
Harney
Hood River
Jefferson
Lake
Lincoln
Malheur
Morrow
Sherman
Tillamook
Union
Wallowa
Wasco
Wheeler

Primary Care: Open
Behavioral Health: Open
Alternative Care: Open
DME: Closed
Specialist: Open

Other: Submit for review
Nominations Panel - Washington
County Specialties

Benton
Clark
Cowlitz
Walla Walla

Primary Care: Open
Behavioral Health: Open
Alternative Care: Closed
DME: Closed
Specialist: Submit for review
Other: Submit for review

*The nominations panel was updated in January 2020 and will be reviewed on an annual basis.

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 60 days of your submission.

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

Moda Health Provider Network

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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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