Administrative forms

• Electronic Funds Transfer / Electronic Remittance Advice Enrollment Form - Allows for electronic transfer of funds to a bank account in lieu of paper checks
• Medical/Vision Claim Form - A fillable PDF for a claim. You may want to consider electronic claim submission instead.
• Provider Data Form - Data about your office for our files
• Medical Provider Nomination Form - Nominate a provider for our panel. Please consider reviewing our panel needs first
• Provider Refund Submission - Submit a refund for over payment on a claim
• Texas provider credentialing form - Texas providers need to complete this state-based credentialing form, but also please consider reviewing our credentialing needs first
• Locum Tenens Form
• Hospital Based Provider Enrollment Form

General Forms

• Advance Directive - A patient’s wishes for their care, should they be too ill or hurt to express it themselves
• Coordination of benefits form - Allows a partner’s or spouse’s coverage to help cover a procedure for a patient
• Provider Inquiry and Appeal Form

Authorization forms

• TDI's Prior Authorization Form for Health Care Services (Medical) - form for prior authorization of medical services from Texas Department of Insurance
• TDI's Prior Authorization Form for Prescription Drug Benefits - form for prior authorization of prescription drugs from Texas Department of Insurance
• Member authorization for Moda Health release of PHI
• Member authorization for provider release of PHI to Moda Health
• Referral/Authorization -referral or authorization form (Moda Health)

Manuals and Policies

• Clinical Editing Policy Information
• Electronic remittance explanation codes
• No Surprises Act - read about our policies to support the No Surprises Act
• Patient rights and responsibilities - access our patients rights and responsibilities policy
• Provider Manual
• Secure Storage and Transport of PHI Policy
• Reimbursement Policy Manual - access our guides to our reimbursement policies

Behavioral Health forms

• Behavioral Health Authorization Request Form
• Moda Health Behavioral Health Specialties form
• Case management referral form

Population-level spoken language report

All community members should have equitable access to healthcare, in their preferred language. To assist our provider network in providing services tailored to their communities' needs, Moda Health provides an annually updated report summarizing which languages are currently being spoken in the areas we serve. Download the report.