Forms

Application forms

Applications are also available online - Apply today

2024

Plan change forms

Use these forms if you would like to make changes to your existing Moda Health plan

Disenrollment form

You may choose to end your Medicare Advantage membership with us. You may also have to end your membership because you have moved out of our service area or for other reasons. Whether you choose to leave or have to leave, to end your membership, please complete the disenrollment form for your plan:

Coordination of benefits (COB)

If you are covered by other medical, vision, pharmacy or dental health plan, we coordinate benefits with other insurers to help you receive the full benefit of those plans.  

Case management form

Case management is a voluntary service for members experiencing complex conditions, catastrophic events, or life altering events, and need assistance managing their situation with a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), or a Behavioral Health LCSW.

To request case management, please call Moda Health Healthcare Services case management at 503-948-5561 or toll-free at 800-592-8283. You can also email casemgmtrefer@modahealth.com, fax a referral to 855-232-6904 or complete and submit our online referral form.

Privacy forms and resources

Access the PHI Authorization Form (allows Moda to disclose your health information to those whom you give us permission), Advance Directive (informs healthcare providers of your wishes for your care) and Appoint a Representative (to request authorization, file a claim, grievance, or appeal). Learn about our adherence to HIPAA privacy practices.

Visit the Privacy Center

Authorizing monthly electronic payment

By completing this form, you give us permission to deduct your monthly premium from a bank account.

Get the Authorization Agreement For Monthly Electronic Funds Transfer (EFT) form

Submitting a pharmacy claim

If you go to an out-of-network pharmacy, you can see if we are able to reimburse any of your costs by completing the pharmacy paper claim form.

Pharmacy paper claim form

Submitting a medical claim

If you need to request reimbursement for medical services, you may submit proof of payment and the itemized bill with this form.

Get the medical claim form

Submitting a routine vision claim

If you need to request reimbursement for routine vision services (such as an eye exam and glasses), you may submit proof of payment and the itemized bill with this form.

VSP reimbursement form

Submitting a dental claim

If you need to request reimbursement for dental services, you may submit proof of payment and the itemized bill with this form.

Get the dental claim form

Making a prescription drug coverage determination request

Coverage determination is a decision about whether or not a prescription drug is covered.

To request coverage determination, you or your provider may do one of the following:

Making a prescription drug coverage redetermination request

A redetermination request is an appeal of a denied coverage determination.

To request coverage redetermination, you or your provider can do one of the following:

Transition/continuity of care

You, as a new enrollee transitioning on to a new plan, or an existing member whose provider network has changed, can request transition or continuity of care.  Your or your treating physician can provide details on the transition or continuity of care form.

Filing a complaint with Medicare

We work to resolve any issues you may have. You can also file a complaint directly with the Centers for Medicare & Medicaid Services (CMS) by using their online form.

Last updated Oct. 1, 2023
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