Provider network participating request form - Oregon Alaska

Interested in joining our provider network? Please complete and submit the new provider network participation request form below. Note:

If you have not already reviewed our nominations panel, please do so before submitting the new provider network participation request form.

Check the panel now

Contracting Request Form for Existing Providers

New provider network participation request form

*Specialty:

*Licensed to Practice In (check all that apply):


*County:
*Burrough:
*Provider name:
*Licensure:
*Current Clinic Name:
*Current Clinic Tax ID:
*Current Clinic Address:
*Date Leaving/Left Clinic (if applicable):
*New Clinic Name:
*New Clinic Tax ID:
*New Clinic Address:
*Starting Date with New Clinic:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:



Medicare PTAN number:
Medicaid Eligible:



Medicaid DMAP number:
*New Clinic Primary Address:
Primary Address Line 2 (optional):
*New Clinic City:
*New Clinic State:
*New Clinic Zip Code:
*Provider first/last name:
*Primary Address:
Primary Address Line 2 (optional):
*City:
*State:
*Zip Code:
*Provider contact first/last name:
*Provider email:
*Office/Contracting first/last name:
*Office/Contracting email:
*Phone number:
Fax:
Notes, description of services:
*Required field  
Are you a behavioral health provider?



Are you currently seeing any Moda members?



Are contracted providers referring our members to you?



Are you requesting to be a Primary Care Provider (PCP)?



If, yes please provide the following information:

Are you a patient centered medical home?



Are you able to provide 24/7 coverage for members?



Are you able to provide pharmaceutical management to members with chronic conditions?




Complete the submission form in full, leaving no blank fields. We will review your information and contact you within 20 business days of your submission. Please note, this request form is for providers that are currently contracted and credentialed and leaving an existing clinic. Providers that submit a request that are not currently contracted and credentialed with Moda Health will not be responded to.

We will review your information and contact you within 60 days of your submission.

You can also submit a print version of this new provider network participation request form. to ProviderNominations@modahealth.com or by fax at ATTN: Provider Nominations 503-243-2964.