Application forms

Choose the correct application form for your location.

Central Oregon – Crook, Deschutes, Jefferson, Hood River and Wasco counties

Eastern Oregon – Baker, Gilliam, Grant, Harney, Lake, Malheur, Morrow, Sherman, Umatilla, Union, Wallowa and Wheeler counties

Northwest Oregon – Clatsop, Columbia, Tillamook, Yamhill, Lincoln, Polk, Marion, Benton, Linn and Lane counties

Portland Metro – Clackamas, Multnomah and Washington counties

Southern Oregon – Coos, Curry, Douglas, Jackson, Josephine and Klamath counties

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.

Plan change form
Disenrollment form

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.

Get the Advance Directive form

Appointing a representative

You can assign someone you trust to request authorization, or file a claim, grievance or appeal.

Get the Appointment of Representative form
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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.

Get 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.

Get the medical claim 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:

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:

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.

Get the Medicare online complaint 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.

Get the Scope of Appointment form

Last updated Sep. 26, 2019

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