Providence Medicare Advantage Plan enrollment forms & documents
Enrollment information
Please visit our how to enroll page and read the enrollment instructions(PDF) before completing enrollment forms.
Once you have completed your enrollment form, fax it to 503-574-8653 or mail to:
Providence Medicare Advantage Plans
P.O. Box 5548
Portland, OR 97228-5548
You will receive a notice in the mail acknowledging receipt of your enrollment request.
Individuals must have both Part A and Part B to enroll.
Reference documents
- Non-discrimination notice (PDF)
- Summary of Benefits
- Optional Supplemental Dental Benefits
- Plan star rating (PDF)
- Important contract information (PDF)
Resources for enrollment
- How to enroll – Helpful information on when and where to enroll
- Premium payment options – Your choices for how to pay your monthly bill
- Premium assistance –You may qualify for extra help
- Medicare Service Area map – Where our plans are offered
Enrollment forms
-
Clackamas, Multnomah, Washington, and Yamhill counties in Oregon
-
Columbia, Lane, Marion, and Polk Counties in Oregon and Clark County in Washington
-
Crook, Deschutes, Hood, Jefferson, and Wheeler counties in Oregon
-
Benton and Linn counties in Oregon
- Enrich + Rx (HMO)(PDF)
-
Spokane county in Washington
-
Snohomish county in Washington
-
DSNP Area (Multnomah, Clackamas, and Washington counties in Oregon)
-
Medical Only No Rx area: Clackamas, Columbia, Lane, Marion, Multnomah, Polk, Washington, Yamhill counties in Oregon and Clark County in Washington
-
Optional supplemental benefit coverage for dental
Do you need some extra assistance?
We're here for you.
If you need assistance with enrollment or with finding the information you need, our Medicare experts are here to assist you any way we can.
Get in touchWebpage is current as of: 06/16/2021