2023 Medicare member forms & documents
Important note:
You may request to have printed EOCs, Provider & Pharmacy Directories and/or Formularies mailed to your home. If you have any questions or need help, don’t hesitate to reach out to one of our Medicare experts to assist you. We’re here to help you in any way we can.
Medicare member forms
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Claims forms
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)
- 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)
Use this form for dates of service on or before 12/31/2021. For services on or after 1/1/2022, use the Medical claim form for Medicare members (above).
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Health education reimbursement form
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Member authorization forms
- Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF)
- Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Spanish (PDF)
- Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Vietnamese (PDF)
- Prior Authorization form for physicians and enrollees (PDF)
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Pharmacy forms
- Coverage determination form (PDF) - updated 10/28/2022
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Privacy forms
- 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)
- 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)
- 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)
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Transition of care form
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Transplant travel reimbursement form
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Plan change forms
To enroll in a different Providence Medicare Advantage Plan follow the steps below:
- 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)
- Complete the form.
- 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
- Providence Medicare Advantage Plans
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.
- Print the change form:
Evidence of Coverage and Annual Notice of Change documents for 2023 Providence Medicare Advantage plans
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For members who receive their coverage through a group or employer only plan
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.
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Providence Medicare Bridge + Rx (HMO-POS)
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Providence Medicare Choice + Rx (HMO-POS)
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Providence Medicare Cottonwood + Rx (HMO-POS)
- Cottonwood + Rx (HMO-POS) Evidence of Coverage (PDF)
- Cottonwood + Rx (HMO-POS) Evidence of Coverage - Spanish (PDF) - updated 10/28/2022
- Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF)
- Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) - updated 10/28/2022
- Summit + Rx (HMO-POS) to Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF)
- Summit + Rx (HMO-POS) to Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) - updated 10/28/2022
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Providence Medicare Dual Plus (HMO D-SNP)
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Providence Medicare Extra + Rx (HMO)
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Providence Medicare Focus Medical (HMO)
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Providence Medicare Pine + Rx (HMO)
- Pine + Rx (HMO) Evidence of Coverage (PDF)
- Pine + Rx (HMO) Evidence of Coverage - Spanish (PDF) - updated 10/28/2022
- Pine + Rx (HMO) Annual Notice of Change (PDF)
- Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF) - updated 10/28/22
- Harbor + Rx (HMO) to Pine + Rx (HMO) Annual Notice of Change (PDF)
- Harbor + Rx (HMO) to Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF) - updated 10/28/2022
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Providence Medicare Prime + Rx (HMO)
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Providence Medicare Reverence (HMO-POS)
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Providence Medicare Sycamore + Rx (HMO)
- Sycamore + Rx (HMO) Evidence of Coverage (PDF)
- Sycamore + Rx (HMO) Evidence of Coverage - Spanish (PDF) - updated 10/28/2022
- Sycamore + Rx (HMO) Evidence of Coverage - Vietnamese (PDF) - updated 10/28/2022
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Providence Medicare Timber + Rx (HMO)
Webpage current as of: 10/28/2022