Providence Medicare Advantage Plan enrollment forms & documents
Enrollment information
Please visit our how to enroll page and read the enrollment instructions 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
- Multi-language insert (PDF) - Updated 4/26/23
- 2025 Summary of Benefits
- 2025 Benefit Highlights
- 2025 Enrollment Guides
- 2024 Summary of Benefits
- 2024 Benefit Highlights
- 2024 Enrollment Guides
- Evidence of Coverage and ANOCs
- Request provider and pharmacy information
- Optional Supplemental Dental Benefits
- Plan star rating
- English | Spanish | Vietnamese | Korean | Russian | Simplified Chinese
- Important contract information (PDF)
- How to appoint a representative (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 – Where our plans are offered
- Pre-Enrollment Checklist
- English | Spanish | Vietnamese | Korean | Russian | Simplified Chinese
2025 Enrollment forms
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Clackamas, Multnomah, Washington, and Yamhill counties in Oregon
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Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk and Wheeler counties in Oregon and Clark County in Washington
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Benton and Linn counties in Oregon
- Extra + Rx (HMO) (PDF)
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Benton, Franklin, Snohomish, Spokane, and Walla Walla counties
- Pine + Rx (HMO), Cottonwood + Rx (HMO-POS) (PDF)
- Pine + Rx (HMO), Cottonwood + Rx (HMO-POS) (Spanish) (PDF) (coming soon)
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Orange county in California
- Sycamore + Rx (HMO) (PDF)
- Sycamore + Rx (HMO) (Spanish) (PDF) (coming soon)
- Sycamore + Rx (HMO) (Vietnamese) (PDF) (coming soon)
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DSNP Area (Multnomah, Clackamas, and Washington counties in Oregon)
- Dual Plus (HMO D-SNP) (PDF)
- Dual Plus (HMO D-SNP) (Spanish) (PDF) (coming soon)
- Dual Plus (HMO D-SNP) (Vietnamese) (PDF) (coming soon)
- Dual Plus (HMO D-SNP) (Russian) (PDF) (coming soon)
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Medical Only, No Rx area: Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington
- Reverence (HMO-POS) (PDF)
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Medical Only, No Rx area: Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Multnomah, Polk, Washington, Wheeler, and Yamhill counties in Oregon and Clark County in Washington
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Optional supplemental benefit coverage for dental
2024 Enrollment forms
-
Clackamas, Multnomah, Washington, and Yamhill counties in Oregon
-
Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk and Wheeler counties in Oregon and Clark County in Washington
-
Benton and Linn counties in Oregon
- Extra + Rx (HMO) (PDF)
-
Benton, Franklin, Snohomish, Spokane, and Walla Walla counties
- Pine + Rx (HMO), Cottonwood + Rx (HMO-POS) (PDF) - (Updated 10/01/2023)
- Pine + Rx (HMO), Cottonwood + Rx (HMO-POS) (Spanish) (PDF)
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Orange county in California
- Sycamore + Rx (HMO) (PDF)
- Sycamore + Rx (HMO) (Spanish) (PDF)
- Sycamore + Rx (HMO) (Vietnamese) (PDF)
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DSNP Area (Multnomah, Clackamas, and Washington counties in Oregon)
- Dual Plus (HMO D-SNP) (PDF)
-
Medical Only, No Rx area: Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington
- Reverence (HMO-POS) (PDF)
-
Medical Only, No Rx area: Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Multnomah, Polk, Washington, Wheeler, and Yamhill counties in Oregon and Clark County in Washington
-
Optional supplemental benefit coverage for dental
Do you need some extra assistance?
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