Forms
- Advance Directive
- Appointment of Representative Form (CMS-1696)
- Authorization Agreement For Monthly Electronic Funds Transfer (EFT)
- Information Request (email requests)
- Scope of Appointment
This link will take you to the Centers for Medicare & Medicaid Services (CMS) Part D Appeals & Grievances page on the CMS web site. You can download the following CMS forms:
- Request a Medicare Prescription Drug Coverage Determination
- Request a Medicare Prescription Drug Redetermination (appeal)
Last updated June 1, 2018
Y0115_WEB_2018A Approved
We're sorry, we don't currently offer Medicare plans in . View our plans in or use the dropdown at the top of the page to view Medicare plans in Oregon.
- Advance Directive
- Appointment of Representative
- Authorization Agreement For Monthly Electronic Funds Transfer (EFT)
- Information Request
- Scope of Appointment
This link will take you to the Centers for Medicare & Medicaid Services (CMS) Part D Appeals & Grievances page on the CMS web site. You can download the following CMS forms:
- Appointment of Representative Form (CMS – 1696)
- Request for a Medicare Prescription Drug Coverage Determination
Last updated October 1, 2016
Y0115_WEB_2017A Approved
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Hello.
We have exciting news to share. ODS is changing its name to Moda Health.
Moda comes from the latin term "modus" and means "a way". We picked it because that's what we are here to do: help our communities find a way to better health.
Together, we can be more, be better.
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