PO Box 40384
Portland, OR 97240
Commercial Authorization / Referral Request Form
(503) 243-4496 (800) 258-2037 Fax (503) 243-5105
If you require a RUSH Prior Authoriaztion for a procedure being done within 48hrs, please
call Moda Health at (503) 243-4496 or (800) 258-2037
PCP / On-Call Doctor Information
Authorization / Referral Information
For Medications Administered in Provider Office Only
Updated 04/13/2017