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 your computer. For that expanded capability you will need to have the complete Adobe Acrobat software package, version 5.0 or later.
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2024 Individual & Family insurance enrollment forms
New applicants - Get a quote
We’ve made it easy to view plan options and get a quote for our health plans. New applicants can get a quote and enroll online by clicking the button below.
Get a quote and enroll
New applicants can also apply for Individual & Family coverage during the Open Enrollment Period, Nov. 1, 2023 - Jan. 15, 2024, using the enrollment forms below.
2024 Oregon Residents
Enrollment forms received between Nov. 1, 2023 – Dec. 31, 2023 will become effective January 1, 2024. Enrollment forms received between Jan. 1, 2024 – Jan. 15, 2024 will become effective February 1, 2024.
2024 Washington Residents
Enrollment applications received between Nov. 1, 2023 – Dec. 15, 2023 will become effective January 1, 2024. Enrollment applications received between Dec. 16, 2023 – Jan. 15, 2024 will become effective February 1, 2024.
Please mail your completed application to:
Providence Health Plan
P.O. Box 4649
Portland, OR 97208-4649
Need assistance?
For help with choosing an Individual & Family plan, please contact our sales team at 503-574-5000 or
800-988-0088 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time), Monday through Friday.
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2023 Individual & Family insurance enrollment forms
New applicants that experience a qualifying event may enroll in a 2023 Individual & Family plan during a Special Enrollment Period, January 1, 2023 - December 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
Need assistance?
For help with choosing an Individual & Family plan, please contact our sales team at 503-574-5000 or 800-988-0088 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time), Monday through Friday.
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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.
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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)
- 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)
- Gene therapy and adoptive cellular travel reimbursement form (PDF)
Vision claim form
- VSP reimbursement form (PDF)
(Use when services are rendered by a non-VSP provider)
For more information
Visit our claims and billing page to learn more about how we handle our processes.
Learn more -
Pharmacy
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Medical home selection
Medical home selections only apply to Choice and Connect plan designs. If you're unsure if this applies to your Providence Health Plan coverage, please contact customer service at 503-574-7500 or 800-878-4445 (TTY: 711).