Forms
Annual Attestations
General forms
- Behavioral Health Authorization Request Form
- Electronic Funds Transfer / Electronic Remittance Advice Enrollment Form
- Provider refund submission form
- Referral/Authorization Form
- Secure Storage and Transport of PHI Policy
- Wavier of Liability — Medicare only
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)
Annual Attestations
- OEBB/PEBB Insurance Requirements
- EOCCO Seclusion & Restraint
-
Diversity, Equity & Inclusion (DEI)
- 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
- 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
- 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
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
Rate finder is now in the Producer Dashboard
Log in with your current username and password to create quotes for groups up to 50.
Producer DashboardLog in
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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