Moda Health member forms
The full list of forms specific to your plan can be found on your Member Dashboard. Below are some general forms for claims and reimbursement requests.
Pharmacy claims
Payments and reimbursements
Communication and information sharing
- Protected health information disclosure authorization form
- Autorización del miembro para permitir la divulgación de información protegida sobre la salud a otra persona o entidad
- Continuity of care (transition of care) request form
- Formulario de solicitud de continuidad de la atención (transición de la atención)