Forms & documents

Enrollment, change of status, & waiver of coverage forms
Oregon small group enrollment forms

2024
2023
Other Oregon small group forms
Oregon large group enrollment forms

2024
2023
Washington enrollment forms

2024
2023
Forms for all groups
- Out-of-area dependent enrollment (PDF)
- Transition of care (PDF)
- Other member forms and notices
- Medical home selection form (PDF)
- Medical home selection form - Spanish (PDF)
- Enrollment spreadsheet (ZIP)
- Employer reconciliation worksheet (PDF)
- HealthEquity standard new business form
- Implementation checklist - HRA (PDF)
- Implementation checklist - HSA (PDF)
- Implementation checklist - FSA (PDF)
Vision claim form
- VSP reimbursement form (PDF)
  (Use when services are rendered by a non-VSP provider)
- Vision claim form (PDF)
  (Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)
Continuation of coverage forms
Termed members may be eligible for continued coverage. The following resources will help administrators determine continuation of coverage eligibility and steps to take to continue coverage.
Health information disclosure forms
Employer toolkits
- Groups sized 50+ Health Coaching Toolkit (PDF)
- Groups sized 50+ Primary Care Provider Toolkit (PDF)
Plan overviews
2024 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
2023 plan overviews
- Employer groups 1-50 (PDF)
- Employer groups 51+ (PDF)
Group size questionnaire
The group size questionnaire is used to determine if Medicare pays primary or secondary to your group health plan coverage. It is also used to determine continuation of coverage.
- Annual group size questionnaire (PDF)