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