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Download a paper application (2014) - Moda Health

Download a paper application (2014) - Moda Health-2025

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The document is an application form for individual health plans offered by Moda Health in Alaska. It outlines eligibility requirements, application types, plan selections, and necessary personal information for applicants and their dependents. The form emphasizes the importance of completing all sections to avoid delays in processing and provides instructions for submission. Additionally, it includes optional health information questions and payment options for premiums.

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Click ‘Get Form’ to open the application in the editor.
Begin with Section 1, Eligibility. Ensure you meet the residency requirements and are not eligible for Medicare.
In Section 2, select your application type and desired effective date. Choose from options like 'New member' or 'Coverage upgrade'.
Proceed to Section 4, Applicant Information. Fill in your personal details including name, marital status, and contact information.
List all family members to be covered under the plan in the designated fields. Attach additional pages if necessary.
If applicable, complete Section 5 regarding health information. This section is optional but can help identify health management needs.
Sign and date the application in Section 7 to certify its accuracy before submission.
Finally, choose your payment option in Section 8 and submit your completed application via mail, fax, or email.

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