Providence Medicare Advantage Plan enrollment forms & documents
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.
- Multi-language insert (PDF) - Updated 4/26/23
- Summary of Benefits
- Plan Comparisons
- Evidence of Coverage
- Optional Supplemental Dental Benefits
- Plan star rating (PDF)
- Plan star rating (Spanish) (PDF)
- Plan star rating (Vietnamese) (PDF)
- 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
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
Orange county in California
- Sycamore + Rx (HMO) (PDF)
- Sycamore + Rx (HMO) (Spanish) (PDF)
- Sycamore + Rx (HMO) (Vietnamese) (PDF)
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?
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 touch