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Provider network participating request form

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.

Check the panel now

Nominations Panel - Oregon
Category Specialties County Status

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Open Counties:
All Counties

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Marriage/Family Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Open Counties:
All Counties

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Open Counties:
Baker, Coos, Curry, Douglas, Grant, Gilliam, Harney, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wheeler

Closed Counties:
Benton, Clackamas, Clatsop, Columbia, Crook, Deschutes, Hood River, Jefferson, Josephine, Klamath, Lane, Linn, Marion, Multnomah, Polk, Jackson, Wallowa, Wasco, Washington, Yamhill

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Open Counties:
Baker, Clatsop, Coos, Curry, Gilliam, Grant, Harney, Jefferson, Lake, Lincoln, Malheur, Morrow, Sherman, Tillamook, Umatilla, Union, Wallowa, Wheeler

Closed Counties:
Benton, Clackamas, Columbia, Crook, Deschutes, Douglas, Hood River, Jackson, Josephine, Klamath, Lane, Linn, Marion, Multnomah, Polk, Wasco, Washington, Yamhill

All Other Specialties

All

Submit for Review

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Submit for Review

Nominations Panel - Washington
Category Specialties County Status

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Open Counties:
Benton
Clark
Cowlitz
Walla Walla

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Marriage/Family Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Open Counties:
Benton
Clark
Cowlitz
Walla Walla

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Open Counties:
Benton, Walla Walla

Closed Counties:
Clark, Cowlitz

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Open Counties:
Benton, Walla Walla

Closed Counties:
Clark, Cowlitz

All Other Specialties

All

Submit for Review:
Benton
Clark
Cowlitz
Walla Walla

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Submit for Review:
Benton, Walla Walla

Closed Counties:
Clark, Cowlitz

Nominations Panel - Idaho
Category Specialties County Status

Primary Care

Family Practice
Geriatrics
Internal Medicine
Pediatrics

Open Counties:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

Behavioral Health

ABA Therapy
Counselors
Licensed Clinical Social Worker
Licensed Family/Marriage Therapist
Psychiatry
Psychology
Mental Health Nurse Practitioner
Substance Use Disorder

Open Counties:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

Alternative Care

Acupuncture
Chiropractic
Massage Therapy
Naturopath

Open Counties:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

Therapies

Physical Therapy
Speech Therapy
Occupational Therapy

Open Counties:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

All Other Specialties

All

Submit for Review:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

DME

All

Closed Counties:
All Counties

Lab

All

Closed Counties:
All Counties

Facilities

Dialysis Center
Home Health
Home Infusion
Hospice
Rehabilitation Center
Skilled Nursing Facility

Submit for Review:
Ada
Adams
Canyon
Gem
Idaho
Owyhee
Payette
Washington

*The nominations panel was updated in December 2021 and is reviewed on an annual basis

New provider network participation request form

*Specialty:

*Licensed to Practice In (check all that apply):






*County:
*Burrough:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:



Medicare PTAN number:
Medicaid Eligible:



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?



Are you currently seeing any Moda members?



Are contracted providers referring our members to you?



Are you requesting to be a Primary Care Provider (PCP)?



If, yes please provide the following information:

Are you a patient centered medical home?




Are you able to provide 24/7 coverage for members?



Are you able to provide pharmaceutical management to members with chronic conditions?




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

You can also submit a print version of this new provider network participation request form. to ProviderNominations@modahealth.com or by fax at ATTN: Provider Nominations 503-243-2964.

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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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