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)
• 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).

• Health education reimbursement form (PDF)

• 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
• Prior Authorization form for physicians and enrollees (PDF)

• Coverage determination form (PDF) - updated 1/9/2023

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)

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)

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)

Request for confidential communications - CA:

• California Request for Confidential Communication form (PDF)

• Transition of care request (PDF)

• Transplant travel reimbursement form (PDF)

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.

• Bridge + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 3/8/23 
• Bridge + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23  
• Bridge 2 + Rx (HMO-POS) to Bridge + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23 
• Compass + Rx (HMO-POS) to Bridge + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23 

• Choice + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 3/8/23
• Choice + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23 
• Choice + Rx 002 (HMO-POS) to Choice + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23
• Latitude + Rx (HMO-POS) to Choice + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23

• Cottonwood + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 3/8/23
• Cottonwood + Rx (HMO-POS) Evidence of Coverage - Spanish (PDF) - Updated 3/8/23
• Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23
• Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) - Updated 3/8/23
• Summit + Rx (HMO-POS) to Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23
• Summit + Rx (HMO-POS) to Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) - Updated 3/8/23

• Dual Plus (HMO D-SNP) Evidence of Coverage (PDF) - Updated 3/8/23
• Dual Plus (HMO D-SNP) Annual Notice of Change (PDF) - Updated 3/8/23

• Extra + Rx (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Extra + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23
• Extra + Rx 002 (HMO) to Extra + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23
• Enrich + Rx (HMO) to Extra + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23

• Focus Medical (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Focus Medical (HMO) Annual Notice of Change (PDF) - Updated 3/8/23

• Pine + Rx (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Pine + Rx (HMO) Evidence of Coverage - Spanish (PDF) - Updated 3/8/23
• Pine + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23
• Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF) - Updated 3/8/23
• Harbor + Rx (HMO) to Pine + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23
• Harbor + Rx (HMO) to Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF) - Updated 3/8/23

• Prime + Rx (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Prime + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23

• Reverence (HMO-POS) Evidence of Coverage (PDF) - Updated 3/8/23
• Reverence (HMO-POS) Annual Notice of Change (PDF) - Updated 3/8/23

• Sycamore + Rx (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Sycamore + Rx (HMO) Evidence of Coverage - Spanish (PDF) - Updated 3/8/23
• Sycamore + Rx (HMO) Evidence of Coverage - Vietnamese (PDF) - Updated 3/8/23

• Timber + Rx (HMO) Evidence of Coverage (PDF) - Updated 3/8/23
• Timber + Rx (HMO) Annual Notice of Change (PDF) - Updated 3/8/23