Member forms

Request access to your health plan records for members of:

• Providence Health Assurance - English (PDF)
• Providence Health Assurance - Arabic (PDF)
• Providence Health Assurance - Chinese (PDF)
• Providence Health Assurance - Russian (PDF)
• Providence Health Assurance - Somali (PDF)
• Providence Health Assurance - Spanish (PDF)
• Providence Health Assurance - Vietnamese (PDF)

Make changes to your health plan records for members of:

• Providence Health Assurance - English (PDF)
• Providence Health Assurance - Arabic (PDF)
• Providence Health Assurance - Chinese (PDF)
• Providence Health Assurance - Russian (PDF) 
• Providence Health Assurance - Somali (PDF) 
• Providence Health Assurance - Spanish (PDF) 
• Providence Health Assurance - Vietnamese (PDF)

Restrict access to your health plan records for members of:

• Providence Health Assurance - English (PDF)
• Providence Health Assurance - Arabic (PDF) 
• Providence Health Assurance - Chinese (PDF)
• Providence Health Assurance - Russian (PDF)
• Providence Health Assurance - Somali (PDF)
• Providence Health Assurance - Spanish (PDF)
• Providence Health Assurance - Vietnamese (PDF)

Allow Providence Health Assurance to share your protected health information with a third party for members of:

• Providence Health Assurance (PDF)

Request for confidential communication endangerment:

If you believe receiving communications at your address could put you in danger, you have the right to request a confidential communication. You can make this request verbally by calling the number on your ID card.

Accounting for disclosures:

You have the right to request a list of certain disclosures of your health information made by Providence Health Assurance. You can make this request verbally by calling the number on your ID card.