Medicare member forms & documents
Important note:
You may request to have a printed EOC 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
-
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 12/31/2020. For services on or after 1/1/2021, use Medical claim form for Medicare members (above).
-
Health education reimbursement form
-
Member authorization forms
-
Provider directory and pharmacy forms
-
Privacy forms
-
Transition of care form
-
Transplant travel reimbursement form
-
Plan change forms
To enroll in a different Providence Medicare Advantage Plan follow the steps below:
- Print the change form:
- Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF)
- Columbia, Lane, Marion, Polk counties in Oregon and Clark county in Washington (PDF)
- Crook, Deschutes, Hood River, Jefferson, and Wheeler counties in Oregon (PDF)
- Spokane and Snohomish counties in Washington (PDF)
- Dual Plus + RX (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 2022 Providence Medicare Advantage plans
-
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.
-
Providence Medicare Choice + Rx 001 (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Choice + Rx 002 (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Compass + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Dual Plus (HMO D-SNP)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Enrich + Rx (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Extra + Rx 001 (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Extra + Rx 002 (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Focus Medical (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Harbor + Rx (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Latitude + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Prime + Rx (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Pine + Rx (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Select Medical (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Summit + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Timber + Rx (HMO)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Bridge 1 + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Bridge 2 + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
-
Providence Medicare Cottonwood + Rx (HMO-POS)
- Evidence of Coverage (PDF)
- Annual Notice of Change (PDF)
Webpage current as of: 12/6/2021