Member forms
Medical and dental
- Dental claim form - members can access their dental claim form at their Member Dashboard
- Medical claim
- Costco hearing aid reimbursement form
- Dental claim form - members can access their dental claim form at their Member Dashboard
- Medical/Vision Claim Form
- Tobacco Cessation Claim Form
- Costco hearing aid reimbursement form
- OTC COVID-19 at home test medical member reimbursement form
Pharmacy
Pharmacy mail order
- Costco - order form or go to pharmacy.costco.com
- PPS - order form or go to PPSrx.com
Pharmacy
Refer to the back side of your member ID card to verify your pharmacy network
Navitus Network
ArrayRx formerly, Northwest Prescription Drug Consortium
- Prescription drug claim form - (use this form for claims incurred on or after January 1, 2022 or for OEBB on or after October 1, 2021)
- Prescription drug claim form - Uniform Medical Plan (UMP) - (use this form for claims incurred on or after January 1, 2022)
- OTC COVID-19 at home test pharmacy member reimbursement form
Pharmacy mail order
Individual Changes
Group applications/changes (through employer)
- Medical & Dental application
- Medical only application
- Dental only application
- Declaration of Domestic Partnership for qualified plans
HIPAA/Privacy
- Authorize Moda Health to use/disclose information about a member - Instructions
- Authorize Moda Health to use/disclose information about a member - Spanish
- Oregon Confidential Communications
Other forms/documents
- Central Peninsula Hospital Non-Emergency Travel Request Form
- Complaint and Appeal Form
- Coordination of Benefits Information
- Dental provider nomination form
- Direct Deposit Form - use this form to have claim reimbursement be directly deposited to your bank account
- Gender-confirming care - overview of gender-confirming care access to medical, surgical, behavioral health and additional support services
- Transition of Care Request form
- Transition of Care (Continuity of Care) - Spanish
- Prior authorization for healthcare travel
- Transition Checklist
- South Peninsula Hospital Non-Emergency Travel Request Form
- Appeals - use to submit an appeal for a processed claim
- Coordination of Benefits form
- Dental provider nomination form
- Direct Deposit Form - use this form to have claim reimbursement be directly deposited to your bank account
- Gender-confirming care - overview of gender-confirming care access to medical, surgical, behavioral health and additional support services
- Disabled Dependent Certification form
- Oregon Medical Provider Nomination Form
- Transition of Care Request Form
- Transition of Care (Continuity of Care) - Spanish
- Transition Checklist
Questions?
If you can't find an answer, please feel free to contact our Customer Service Customer Service Customer Service
Questions?
If you can't find an answer, please feel free to contact our Customer Service
Employer web tools
Benefit Tracker
Check benefits, eligibility, incentive and utilization
Rate finder is now in the Producer Dashboard
Log in with your current username and password to create quotes for groups up to 50.
Producer DashboardLog in
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.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
Hello.
Please select the state you live in, or the state where your employer is headquartered, so we can tailor your experience:
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