Individual & Family forms
To view, fill out and print the forms on this page, you will need the latest version of Adobe Acrobat Reader, which can be downloaded. However, Adobe Acrobat Reader does not allow you to save your completed, or partially completed, forms to a disk or on your computer. For that expanded capability you will need to have the complete Adobe Acrobat software package, version 5.0 or later.
2023 Individual & Family insurance enrollment forms
New applicants - Get a quote and enroll today
We've made it easy to get a rate quote for our health plans and to enroll online.
Get a quote and enroll online today
New applicants that experience a qualifying event may enroll in a 2023 Individual and Family plan during a Special Enrollment Period, Jan. 1, 2023 - Dec. 31, 2023, using the enrollment forms below.
2023 Oregon Residents
2023 Washington Residents
Please mail your completed application to:
Providence Health Plan
P.O. Box 4649
Portland, OR 97208-4649
For help with choosing an Individual and Family plan, please contact our Sales team at 503-574-5000 or 800-988-0088 (TTY: 711), Monday through Friday 8 a.m. to 5 p.m. (Pacific Time).
Transition of care
Use the Transition of Care form when you experience a change of benefits and need assistance transitioning care for current or previous services received from a prior health plan.
Claims and billing
Most providers bill Providence Health Plan directly; however, if you must submit a medical claim to Providence, please use these forms:
- Medical claim form (PDF)
- Mental health/chemical dependency claim form (PDF)
For Providence St. Joseph Caregivers ONLY, use this form for mental health/chemical dependency reimbursements (all dates of service).
- Alternative care claim form (PDF)
(Please have your provider complete the Alternative Care Claim Form)
- Medical travel reimbursement form (PDF)
- Oregon transplant travel reimbursement form (PDF)
- Washington transplant travel reimbursement form (PDF)
- COVID-19 at-home testing member reimbursement form (PDF)
Vision claim forms
- 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)
For more information
Visit our claims and billing page to learn more about how we handle our processes.
Medical home selection
For Providence Individual and Family plan members enrolled on a Connect or Choice network plan.