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.

Medical claims

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

Pharmacy claims

• Prescription drug claim form

Payments and reimbursements

• Direct deposit authorization form
• Autopay EFT authorization agreement (for individual plans)
• Coordination of benefits form
• Out-of-pocket expense credits form

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
• How to complete these PHI disclosure forms
• Continuity of care (transition of care) request form
• Formulario de solicitud de continuidad de la atención (transición de la atención)

Authorization of coverage

• Complaint and appeal form
• Disabled dependent certification form
• Doula reimbursement form

Other

• Medical provider nomination request form