Medicare authorization

This form may be returned unprocessed if not completely filled out with all requested information. Authorizations will be given for medically necessary services only. This request cannot be processed without supporting documentation.

(Completed within 14 days of receipt.)
(Choose ONLY if you are attesting that waiting for
a decision under the standard time frame could place the enrolleeā€™s life, health, or ability to regain maximum function in serious jeopardy. Completed within 72 hours of receipt.)

Section > 1 Patient Information

Section > 2 Requesting provider (PPO plans) primary care provider (HMO plans) information

Section > 3 Servicing provider or specialist information

Section > 4 Facility Information

Section > 5 Service Requested

CPT-4/HCPCS code
Description of procedure or services

Ready to submit? Fax to 855-637-2666 or mail to
Moda Health, Attn: Medicare Authorization Department, PO Box 40384, Portland, OR 97240
Questions? Call us toll-free at 1-800-592-8283.