• Requesting access to your health plan records (PDF)
• Changing and restricting access to your health plan records (PDF)
• Request for Confidential Communications (PDF)
• Allowing Providence Health Plan to share your protected health information (PDF) 

New applicants - Get a quote and enroll today

We've made it easy to get a rate quote for our health plans and enroll online.

Providence Individual and Family plans open enrollment is closed.

Current members that experience a qualifying event during the special enrollment period, Jan. 16 – Dec. 31, 2022, can make changes to their plan using the forms below.

2022 Oregon plans

With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Federal Health Insurance Marketplace policy, go to HealthCare.gov to make changes.

• 2022 online change form for Individual and Family insurance
• 2022 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)

2022 Washington plans

With this form, you can change your plan, add or remove dependents, or terminate your coverage.

• 2022 online change form for Individual and Family insurance
• 2022 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)

The special enrollment period for 2021 Individual and Family plan coverage deadline was November 30, 2021; however, you can still apply for and get health insurance coverage if you experience an eligible retroactive qualifying life event such as birth, adoption, or acquisition of legal guardianship.

If you have experienced a qualifying event eligible for a retroactive enrollment, you may use the application below to enroll for Individual and Family insurance.

• 2021 fillable application for Oregon Individual and Family insurance (PDF)
• 2021 fillable application for Washington Individual and Family insurance (PDF)

Questions?

For help with choosing an Individual and Family plan, please contact our Sales team at 503-574-5000 or 1-800-988-0088 (TTY: 711), Monday through Friday 8 a.m. to 5 p.m. (Pacific Time).

Current members can make changes to their 2021 plan using the forms below.

2021 Oregon plans

If you have experienced a qualifying event eligible for a retroactive effective date, you may use the links below to make changes to your 2021 plan. With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Federal Health Insurance Marketplace policy, go to HealthCare.gov to make changes.

• 2021 online change form for Individual and Family insurance
• 2021 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents)

2021 Washington plans

If you have experienced a qualifying event eligible for a retroactive effective date, you may use the links below to make changes to your 2021 plan. With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Washington Health Benefit Exchange policy, go to WaHealthPlanFinder.org to make changes.

• 2021 online change form for Individual and Family insurance
• 2021 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents)

Get a quote today

We've made it easy to get a quote on your rates for our health plans. 

• Transition of care request (PDF)

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 for providers (PDF)
• Medical travel reimbursement form (PDF)
• Transplant travel 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.

• Prescription drug reimbursement request form (PDF)
• Prescription drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)

• Medical home selection form (PDF)
• Formulario de Providence para la selección de hogar médico (PDF)