Moda Health forms and guides

Get the tools you need to successfully onboard and manage your clients. From administrator guides to electronic services agreements, this page houses the essentials for setting up and supporting a Moda Health plan.

Group Administrator Guide

Explore our overview of roles, processes and key contacts for managing group coverage.

Explore the guide

Transition checklist

Help your clients smoothly switch to Moda Health with this step-by-step onboarding checklist.

Explore the checklist

Group applications and plan confirmation

Find everything you need to set up small and large group coverage with Moda Health, including applications by group size and plan year, and confirmation forms to finalize selections.

Group applications

2026 Small Group (1-50 employees) application

2026 Large Group (51+ employees) application 

Enroll new or renewing groups:

Green enrollment spreadsheet

Plan confirmation forms

Set up electronic funds transfer for group premium payments:

2026 Small Group Plan Confirmation form

For groups submitting paperwork after the effective date:

Late acknowledgement form

Agreements and authorizations

Set up electronic funds transfer for group premium payments:

Authorization agreement form (EFT) - Group

For fully insured groups with 51+ enrolled employees:

Electronic Services Agreement – 51+ Fully Insured

For self-funded groups using administrative services only (ASO) plans.

Electronic Services Agreement – ASO:

Authorization form allowing the disclosure of protected health information to another person/entity:

Protected Health Information (PHI) disclosure authorization

Individual and family plans

Access individual and family plan applications to help enroll members with confidence.

Applications

Medicare Supplement applications

Help clients get more from their Medicare with Moda Health’s Medicare Supplement plans.

Enrollment and change forms

Find the right enrollment form for your group’s setup, whether it’s medical, dental or a combination. Most forms are also available in Español

Standard enrollment forms

These forms are for new enrollments and member changes.

Domestic partnership declarations

Declaration of Domestic Partnership

Claims and coordination forms

Help your clients navigate claims submissions and benefits coordination with these downloadable forms.

Members can submit out-of-network medical or vision claims:

Medical/Vision claim form

Members can view this form by logging in to their Member Dashboard:

Dental claim form on Member Dashboard

Use this form for reimbursement of tobacco cessation program expenses:

Tobacco cessation claim form

This form is required when a member has other health coverage:

Coordination of Benefits

Additional tools

Have questions?

Your Moda Health sales team is here to help you compare options, generate quotes and find what you need.

Contact the Moda Health sales team