Choose the correct application form for your location.
Optional, supplemental benefit application - Extra Care
Plan change forms
Use these forms if you would like to make changes to your existing Moda Health plan.
Giving Advance Directive
An Advance Directive lets healthcare providers know your wishes for your care. They would use the Advance Directive if you were unable to communicate. Use this form to give instructions about life support, appoint a representative and more.
Appointing a representative
You can assign someone you trust to request authorization, or file a claim, grievance or appeal.
Authorizing monthly electronic payment
By completing this form, you give us permission to deduct your monthly premium from a bank account.
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.
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.
Making a pharmacy 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:
- Complete our online Coverage determination and exception request (members and providers) form
- Please call our Moda Health Customer Service at 503-265-4709 or toll-free at 888-786-7509. TTY users, dial 711. Customer Service is available to help you from 7 a.m. to 8 p.m., Monday through Friday. Weekend calls are forwarded to voicemail and returned the next day.
- Mail your request by completing this coverage determination and exception request form
Making a 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:
- Complete our online Prescription drug redetermination request form
- Contact Moda Health Pharmacy Customer Service at 888-786-7509. TTY users, dial 711.
- Mail your request by completing this coverage prescription drug redetermination request 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.
Planning your sales appointment
Your agent will need a Scope of Appointment form before talking with you about Medicare plans. You can use this form to let the agent know which options interest you.
Last updated Sep. 26, 2019