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 coming soon)
• 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)
• Mental health/chemical dependency claim form for Medicare members  (PDF coming soon)
  Use this form for dates of service on or before 12/31/2020. For services on or after 1/1/2021, use Medical claim form for Medicare members (above).

• Health education reimbursement form (PDF coming soon)

• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF coming soon)
• Prior Authorization form for physicians and enrollees (PDF coming soon)

• Coverage determination form (PDF coming soon)

• Request access to your health plan records (PDF)
• Make changes to your health plan record (PDF)
• Restrict access to your health plan records (PDF)

• Transition of care request (PDF coming soon)

• Transplant travel reimbursement form (PDF coming soon)

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

1. Print the change form: 
   
   • 2023 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF)
   • 2023 Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington (PDF)
   • 2023 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington (PDF)
   • 2023 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon (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
   • 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.

To view the Evidence of Coverage (EOC) or Summary of Benefits (SB) for your 2022 Providence Medicare Advantage Plan, please log in to your myProvidence account.

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

• Evidence of Coverage (PDF coming soon) 
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon) 
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)

• Evidence of Coverage (PDF coming soon)
• Annual Notice of Change (PDF coming soon)