Forms
Claim forms
Credentialing forms
- DMAP Enrollment Form
- Hospital Based Enrollment Form
- Organizational Provider Credentialing Application
- Clinic diversity data – submit diversity, equity, and inclusion focused information for contracted clinics/facilities
- Provider diversity data – submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
General forms
General forms
- Advance Directive
- Alcohol and/or Drug Dependence Screening - Adults & Adolescents
- Behavioral Health Authorization Request Form
- Case management referral form
- Electronic Funds Transfer / Electronic Remittance Advice Enrollment Form
- Material Risk Notice
- Medical/Vision Claim Form
- OHLC Provider Data Form
- Oregon Medical Provider Nomination Form
- Prenatal/Postpartum fax
- Provider refund submission form
- Provider Roster - Template
- PHQ-9 | Scoring instructions
- Referral/Authorization - Commercial Only
- Referral/Authorization - Medicare only
- Rx Preauthorization
- Secure Storage and Transport of PHI Policy
- Wavier of Liability — Medicare only
Credentialing forms
- DMAP Enrollment Form
- Hospital Based Enrollment Form
- Organizational Provider Credentialing Application
- Clinic diversity data – submit diversity, equity, and inclusion focused information for contracted clinics/facilities
- Provider diversity data – submit diversity, equity, and inclusion focused information for yourself (contracted practitioners)
Mind Body Connection
To improve coordination of care between PCPs and Mental Health Providers for Southern Oregon residents, the Mind Body Connection (MBC) collaborative was established in 2005. MBC created a Notice of Referral/Consent For the Release of Information form for OHP members. This form exists to enhance communication of vital information between mental and physical health care providers via a legal release of information signed by the patient, parent or legal guardian. Moda Health partners with Family Care and Mid Rogue Health Plan to distribute this tool to providers in Jackson County. Please use this new form with all OHP patients in Jackson County. You may download the form and checklist using the links below.
Credentialing forms
General forms
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
Employer web tools
Benefit Tracker
Check benefits, eligibility, incentive and utilization
Producer web tools
- Fully Insured Quotes (1-50)
- Equal Funding Quotes (25-99)
- Corporate reports
- eCommissions
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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