Get Moda Reimbursement Form

This guide provides a clear and supportive walkthrough on filling out the Moda Reimbursement Form online. Following these steps will help ensure that you complete the form accurately and efficiently for your reimbursement needs.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the reimbursement form and open it in your preferred editor.
2. Fill in the required sections, starting with your ODS Member ID number and Group ID number, ensuring accurate data entry.
3. In Section 1, provide patient information including last name, first name, middle initial, address (street, city, state, zip code), date of birth, home phone, and cell phone number.
4. Indicate the gender by checking the appropriate option (male or female).
5. Proceed to Section 2, where you will need to read the authorization statement and confirm that the information provided is true. Sign and date the form.
6. Obtain the Hearing Specialist's completion of their part of the claim form and ensure it is returned to you.
7. Make copies of the claim form along with your payment receipt from .
8. Submit both the copied claim form and receipt to ODS via the specified mail or email options.
9. Once submitted, you may save any changes before downloading, printing, or sharing the form.

Complete your Moda Reimbursement Form online today to ensure prompt processing of your claim.