Moda Health medical provider contracting request

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

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

Nominations Panel - Oregon
County	Specialties
Clackamas Multnomah Washington	Primary Care: Open Behavioral Health: Submit for review Alternative Care: Closed DME: Closed Specialist: Closed Other: Submit for review
Benton Lane Marion Polk Jackson Yamhill	Primary Care: Open Behavioral Health: Open Alternative Care: Submit for review DME: Closed Specialist: Closed to Neonatology, Oncology, Sports Medicine, Vascular Surgery only Other: Submit for review
Columbia Coos Deschutes Josephine Klamath Linn Umatilla	Primary Care: Open Behavioral Health: Open Alternative Care: Submit for Review DME: Closed Specialist: Submit for review Other: Submit for review
Baker Clatsop Crook Curry Grant Gilliam Harney Hood River Jefferson Lake Lincoln Malheur Morrow Sherman Tillamook Union Wallowa Wasco Wheeler	Primary Care: Open Behavioral Health: Open Alternative Care: Open DME: Closed Specialist: Submit for review Other: Submit for review

Nominations Panel - Washington
County	Specialties
Benton Clark Cowlitz Walla Walla	Primary Care: Open Behavioral Health: Open Alternative Care: Submit for review DME: Closed Specialist: Submit for review Other: Submit for review

Nominations Panel - Idaho
County	Specialties
Ada Adams Canyon Gem Idaho Owyhee Payette Washington	Primary Care: Open Behavioral Health: Open Alternative Care: Submit for Review DME: Closed Specialist: Submit for review Other: Submit for review

*The nominations panel was updated in June 2021 and will be reviewed on an annual basis.

New provider network participation request form

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

*Specialty:
*Licensed to Practice In (check all that apply): Alaska Oregon Washington Texas None
*County:
*Burrough:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:
Yes No
Medicare PTAN number:
Medicaid Eligible:
Yes No
Medicaid DMAP number:
*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?
Yes No
Are you currently seeing any Moda members?
Yes No
Are contracted providers referring our members to you?
Yes No
Are you requesting to be a Primary Care Provider (PCP)?
Yes No
If, yes please provide the following information:
Are you a patient centered medical home?
Yes No
Are you able to provide 24/7 coverage for members?
Yes No
Are you able to provide pharmaceutical management to members with chronic conditions?
Yes No

Provider network participating request form