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
- Plan star rating (PDF)
- Important contract informationPDF)
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
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Clackamas, Multnomah, Washington, and Yamhill counties in Oregon
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Columbia, Lane, Marion, Polk, and Clark counties in Oregon
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Crook, Deschutes, Hood, Jefferson, and Wheeler counties in Oregon
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Benton and Linn counties in Oregon
- Enrich + Rx (HMO)(PDF)
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Spokane county in Washington
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Snohomish county in Washinton
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DSNP Area (Multnomah, Clackamas, and Washington counties in Oregon)
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Medical Only No Rx area: Clackamas, Columbia, Lane, Marion, Multnomah, Polk, Washington, Yamhill counties in Oregon and Clark County in Washington
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Optional supplemental benefit coverage for dental
Do you need some extra assistance?
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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.
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