Moda Health member forms

Medical claims

• Medical and vision claim form
• Tobacco cessation claim form
• Costco hearing aid reimbursement form

Pharmacy claims

Verify your pharmacy network on the back of your member ID card to select the correct form(s).

• Prescription drug claim form
• Prescription drug claim form (Uniform Medical Plan (UMP))

Payments and reimbursements

• Direct deposit authorization form
• Autopay EFT authorization agreement (for individual plans)
• Coordination of benefits form

Communication and information sharing

• Protected health information disclosure authorization form
• (How to complete this 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)
• Request for confidential communications form

Authorization of coverage

• Complaint and appeal form
• Disabled dependent certification form
• Doula reimbursement form
• Deductible and out-of-pocket maximum form

Group applications and changes (through employer)

• Medical enrollment application and change of information form
• Declaration of domestic partnership