Most providers bill the plan directly; however, if you must submit a medical claim to Providence, please use these forms:

• Medical claim form for Medicare members (PDF)
• Medical claim form for Medicare members - Spanish (PDF)
• Medical claim form for Medicare members - Vietnamese (PDF)
• CMS appointment of representative form for Medicare members (PDF)
  (Medicare members must complete this authorization form when someone is submitting a member reimbursement request on their behalf)
• For Mental Health/Chemical Dependency, please use the medical claim form for Medicare members.

• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF) - updated 3/17/2023
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Spanish (PDF) - updated 3/17/2023
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Vietnamese (PDF) - updated 3/17/2023
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Russian (PDF)
• Prior Authorization form for physicians and enrollees (PDF)

• Coverage determination form (PDF) - updated 1/9/2023
• Direct Member Reimbursement Form (PDF) 

Request access to your health plan records:

• Request access to your health plan records (PDF)
• Request access to your health plan records - Spanish (PDF)
• Request access to your health plan records - Vietnamese (PDF)
• Request access to your health plan records - Russian (PDF)

Make changes to your health plan records:

• Make changes to your health plan record (PDF)
• Make changes to your health plan record - Spanish (PDF)
• Make changes to your health plan record - Vietnamese (PDF)
• Make changes to your health plan record - Russian (PDF)

Restrict access to your health plan records:

• Restrict access to your health plan records (PDF)
• Restrict access to your health plan records - Spanish (PDF)
• Restrict access to your health plan records - Vietnamese (PDF)
• Restrict access to your health plan records - Russian (PDF)

Request for confidential communications - CA:

• California Request for Confidential Communication form (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.

Our Care Management team is ready and available to assist you with things like transitioning from one health plan to another, finding and establishing with a new physical or behavioral health provider, coordination between providers, and much more.

Go to our transition of care page to learn more about all the support our team can provide and how to get started.

• Transplant travel reimbursement form (PDF)

To enroll in a different Providence Medicare Advantage Plan follow the steps below:

 

1. Print the change form: 
   
   • 2025 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF)
   • 2025 Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington (PDF)
   • 2025 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington (PDF)
   • 2025 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington - Spanish (PDF)
   • 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon (PDF)
   • 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Spanish (PDF)
   • 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Vietnamese (PDF)
   • 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Russian (PDF)


2. Complete the form.


3. Mail to Providence Medicare Advantage Plans at:
   
   
   • Providence Medicare Advantage Plans
     P.O. Box 5548
     Portland, OR 97228-5548
     provMedicare@providence.org
   • Or fax to 503-574-8607

You will receive a notice in the mail acknowledging receipt of the completed plan change or a request for additional information if the form is not complete.

Some items may not show as covered at checkout. If you believe an item should be covered and you have paid for those items yourself please complete the reimbursement form. 

OTC reimbursement form (PDF) 
OTC reimbursement form Spanish (PDF) 
OTC reimbursement form Russian (PDF) 
OTC reimbursement form Vietnamese (PDF) 

To view the Evidence of Coverage (EOC) or Summary of Benefits (SB) for your 2025 Providence Medicare Advantage Plan, please log in to your myProvidence account.

You can also request to have a printed EOC mailed to your home.

• Bridge + Rx (HMO-POS) Evidence of Coverage (PDF) 
• Bridge + Rx (HMO-POS) Annual Notice of Change (PDF) 

• Choice + Rx (HMO-POS) Evidence of Coverage (PDF) 
• Choice + Rx (HMO-POS) Annual Notice of Change (PDF) 

• Cottonwood + Rx (HMO-POS) Evidence of Coverage (PDF)
• Cottonwood + Rx (HMO-POS) Evidence of Coverage - Spanish (PDF)
• Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF)
• Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) 

• Dual Plus (HMO D-SNP) Evidence of Coverage (PDF) 
• Dual Plus (HMO-D-SNP) Evidence of Coverage - Spanish (PDF)
• Dual Plus (HMO-D-SNP) Evidence of Coverage - Vietnamese (PDF)
• Dual Plus (HMO-D-SNP) Evidence of Coverage - Russian (PDF)
• Dual Plus (HMO D-SNP) Annual Notice of Change (PDF) 
• Dual Plus (HMO D-SNP) Annual Notice of Change - Spanish (PDF) 
• Dual Plus (HMO D-SNP) Annual Notice of Change - Vietnamese (PDF)
• Dual Plus (HMO D-SNP) Annual Notice of Change - Russian (PDF)

• Extra + Rx (HMO) Evidence of Coverage (PDF) 
• Extra + Rx (HMO) Annual Notice of Change (PDF) 

• Focus Medical (HMO) Evidence of Coverage (PDF) 
• Focus Medical (HMO) Annual Notice of Change (PDF) 

• Pine + Rx (HMO) Evidence of Coverage (PDF)
• Pine + Rx (HMO) Evidence of Coverage - Spanish (PDF)
• Pine + Rx (HMO) Annual Notice of Change (PDF) 
• Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF)

• Prime + Rx (HMO) Evidence of Coverage (PDF) 
• Prime + Rx (HMO) Annual Notice of Change (PDF) 

• Reverence (HMO-POS) Evidence of Coverage (PDF) 
• Reverence (HMO-POS) Annual Notice of Change (PDF) 

• Sycamore + Rx (HMO) Evidence of Coverage (PDF) 
• Sycamore + Rx (HMO) Evidence of Coverage - Spanish (PDF) 
• Sycamore + Rx (HMO) Evidence of Coverage - Vietnamese (PDF)
• Sycamore + Rx (HMO) Annual Notice of Change (PDF) 
• Sycamore + Rx (HMO) Annual Notice of Change - Spanish (PDF)
• Sycamore + Rx (HMO) Annual Notice of Change - Vietnamese (PDF)

• Timber + Rx (HMO) Evidence of Coverage (PDF) 
• Timber + Rx (HMO) Annual Notice of Change (PDF)