Moda Health medical provider
nomination request
Section 1 Nomination information
To nominate your provider, please fill out the Member Information section below. New provider participation is contingent on
credentialing approval, network needs, state and federal regulations, and other factors.
If your provider would like to initiate a network participation request, have them visit and submit a new contract request via the web, mail, or fax.
Ready to submit? Return this form to your provider's office, and let them know you would like them to initiate a network
participation request with Moda Health.
Once your provider's application has been reviewed, a Moda Health Contract Negotiator will contact them to initiate a participation
agreement within 30-60 business days.
Please note: Not all nominated providers will be eligible for participation, and/or not all will choose to participate with any or all
Moda Health networks.
Section 2 Member information
Name (first) Name (M.I.) Name (last) Date (mm/dd/yyyy)
Phone Email
Employer group name Which network do you belong to?
Reason for request
Additional considerations
Section 3 Provider information
Name Business name
Provider type Address/location
Phone Email
Questions? We're here to help. Contact the Moda Health Sales and Service Department
toll-free at 800-578-1402. (TTY users, dial 711.)
Health plans provided by Moda Health Plan, Inc. Individual medical plans in Alaska provided by Moda Assurance Company. 59889464 (10/19)