Moda Health medical provider contracting request

Interested in joining our provider network? Please complete and submit the new provider network participation request form below. Note:

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 - Alaska
Category	Specialties	Burrough Status
Diversity, Equity & Inclusion (DEI) Providers NOTE: use the DEI Provider Contract request form	Providers who identify as or provide: Black/African American Centered Care Hispanic and Latinx Centered Care Indigenous/Native American Centered Care Asian and Pacific Islander Centered Care LGBTQIA+ Centered Care Sensory Disability Centered Care Intellectual and Developmental Disability Centered Care Veteran Centered Care Bilingual Care Culturally Specific Care Gender Affirming Care	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Primary Care	Family Practice Geriatrics Internal Medicine Pediatrics	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Behavioral Health	ABA Therapy Counselors Licensed Clinical Social Worker Licensed Family/Marriage Therapist Psychiatry Psychology Mental Health Nurse Practitioner Substance Use Disorder	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Alternative Care	Acupuncture Chiropractic Massage Therapy Naturopath	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Therapies	Physical Therapy Speech Therapy Occupational Therapy	Open Burroughs: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
All Other Specialties	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
DME	All	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell
Lab	All	Closed Burroughs: All Burroughs
Facilities	Dialysis Center Home Health Home Infusion Hospice Rehabilitation Center Skilled Nursing Facility	Submit for Review: Anchorage Fairbanks Haines Hannah-Angoon Juneau Kenai Peninsula Ketchikan Gateway Matanuska-Susitna Petersburg Prince of Wales Sitka Skagway Wrangell

*Specialty:
*Licensed to Practice In (check all that apply): Alaska Oregon Washington Idaho Texas None
*County:
*Burrough:
*Provider name:
*Licensure:
*Current Clinic Name:
*Current Clinic Tax ID:
*Current Clinic Address:
*Date Leaving/Left Clinic (if applicable):
*New Clinic Name:
*New Clinic Tax ID:
*New Clinic Address:
*Starting Date with New Clinic:
*Business/Provider name:
*Tax ID:
*Type 1 NPI (Individual - if applicable):
*Type 2 NPI (Organizational - if applicable):
Medicare Eligible:
Yes No
Medicare PTAN number:
Medicaid Eligible:
Yes No
Medicaid DMAP number:
*New Clinic Primary Address:
Primary Address Line 2 (optional):
*New Clinic City:
*New Clinic State:
*New Clinic Zip Code:
*Provider first/last name:
*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?
Yes No
Are you currently seeing any Moda members?
Yes No
Are contracted providers referring our members to you?
Yes No
Are you requesting to be a Primary Care Provider (PCP)?
Yes No
If, yes please provide the following information:
Are you a patient centered medical home?
Yes No
Are you able to provide 24/7 coverage for members?
Yes No
Are you able to provide pharmaceutical management to members with chronic conditions?
Yes No

Provider network participating request form - Oregon Alaska

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Contracting Request Form for Existing Providers

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Provider network participating request form - Oregon Alaska

Check the panel now

Contracting Request Form for Existing Providers

New provider network participation request form

Moda Health Provider Network

Opt in for medical

Member Dashboard

Questions?

Questions?

Employer web tools

Benefit Tracker

Provider Reports

Join our email list

Benefit Tracker

Producer web tools

Privacy alert

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