Forms and documents

Members should log in to their Member Dashboard for personalized set of resources.

Gender-confirming care - overview of gender-confirming care access to medical, surgical, behavioral health and additional support services
How to read an EOB – use this guide to understand the information in an explanation of benefits (EOB). You can access EOBs in your Member Dashboard.
ID card - access or download a copy of your Member ID Card
No Surprises Act - read about our policies to support the No Surprises Act
Out of Pocket Expense Credits
Preventive services - list of routine exams, immunizations and screenings for members
Transparency in coverage - learn about our cost-sharing policies and procedures

Appeal form – submit an appeal if you disagree with a claim/EOB
COVID-19 OTC at home test medical member reimbursement form - claim form for COVID-19 at home tests, See our COVID FAQ page for more details.
Coordination of benefits - form to coordinate benefits from member's additional coverage
Declaration of Domestic Partnership – use this affidavit to add someone to a qualified plan
Individual EFT - Authorization agreement for autopay form
Medical claim form – submit a medical claim manually using the mailing address and fax number on the form
Medical procedure cost estimate - submit form to receive an estimate for a planned medical procedure
Pharmacy claim form - submit a pharmacy claim manually using the mailing address or fax number on the form
Protected Health Information (PHI) Disclosure Authorization – Authorize Moda Health to use/disclose information about a member (see instructions for more details)
Transition of care - new enrollee transitioning on to a new plan or an existing member whose provider network has changed
Transición de la atención - nuevo miembro inscrito que pasa a un nuevo plan o continuidad de la atención: miembro existente cuya red de proveedores ha cambiado