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Contracting

New provider contracting request form

Want to join Moda Health's select provider network? This page has everything you need to submit a request to become a participating provider with us.

Upon completing the following form, 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.

To get 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.

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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