Self-funded member forms & documents

• PHI Authorization Form (PDF)
• PHI Authorization Form (Spanish) (PDF)
• Appointment of Authorized Representative (PDF)
• Appointment of Authorized Representative (Spanish) (PDF)
• Confidential Communication Request Form (PDF)
• Restriction Request Form (PDF)

Choice and Connect plan members are required to choose a medical home (not a PCP) for yourself and each covered dependent.

To make your selection:

• Log in to your My Collective® account.
• Navigate to the Get Care provider search and choose a provider.
• Click ‘Set as my medical home.’

Need help? Call a Member Advocate at 855-526-3824, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

• How to Choose a Patient-centered Medical Home (PDF)

Members on Oregon health plans are required to choose a PCP for yourself and each covered dependent, due to Oregon Senate Bill 1529. You must choose your PCP within 90 days of the start of your Providence Health Plan Powered by Collective Health coverage. If you do not choose a PCP within 90 days, we will assign one to you.

To make your selection:

• Log in to your My Collective® account.
• Navigate to the Get Care provider search and choose a provider.
• Click ‘Set as my primary care provider.’

Need help? Call a Member Advocate at 855-526-3824, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

• How to Choose a Primary Care Provider (PDF)

• Continuity of Care and Transition of Care Request Form (PDF)

Most providers bill to Providence Health Plan Powered by Collective Health directly, however there may be times when you need to submit a medical claim.

To be reimbursed for health care services on or after January 1, 2026, you will need to submit a claim through your My Collective® online portal or mobile app using the following steps:

• Log in to your My Collective account.
• At the top of the page, go to "Activity"
• Click "Submit a claim."

Need help? Call a Member Advocate at 855-526-3824, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

• Prescription Drug Reimbursement Request Form (PDF)
• Prescription Drug Prior Authorization Form (PDF)
• Uniform Prior Authorization Prescription Request Form (PDF)

• Request for Additional Acupuncture Care Sessions (PDF)
• Request for Additional Chiropractic Care Sessions (PDF)

Gap exceptions address gaps in the medical network of contracted providers. Requesting a network gap exception from Providence Health Plan Powered by Collective Health is formally asking the health plan to cover care from an out-of-network provider at in-network cost-sharing rates.

• Network Gap Exception Request (PDF)
• Network Gap Exception Request for Major Surgery (PDF)

Learn more about network gap exceptions below.

• Understanding Gap Exceptions (PDF)

Please use this form to request coverage of fertility preservation services before receiving these services from a provider.

• Fertility Preservation for Gender Affirming Service Recipients Benefit Request Form (PDF)

You have the right to review an internal appeal. This allows you to ask Providence Health Plan Powered by Collective Health to reconsider a decision about coverage or payment for medical services. They'll review and may reverse their initial decision.

• Request for Internal Appeal Form (PDF)
• Request for Internal Appeal Form (Spanish) (PDF)

If Providence Health Plan Powered by Collective Health denies coverage or payment for medical services and you disagree with their decision, you can request an external review. This is done by an independent third party. They’ll review the situation and make a final decision.

• External Review Request Form (PDF)