Providence Individual and Family plans open enrollment is closed.

Current members that experience a qualifying event between Jan. 1 – Dec. 31, 2022, can make changes to their plan using the forms below.

2022 Oregon plans

With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Federal Health Insurance Marketplace policy, go to HealthCare.gov to make changes.

• 2022 online change form for Individual and Family insurance
• 2022 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)

2022 Washington plans

With this form, you can change your plan, add or remove dependents, or terminate your coverage.

• 2022 online change form for Individual and Family insurance
• 2022 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)

Request access to your health plan records for members of:

• Providence Health Plan (PDF)
• Providence Medicare Advantage Plan (PDF)
• Health Share of Oregon (Medicaid) (PDF)

Make changes to your health plan records for members of:

• Providence Health Plan (PDF)
• Providence Medicare Advantage Plan (PDF)
• Health Share of Oregon (Medicaid) (PDF)

Restrict access to your health plan records for members of:

• Providence Health Plan (PDF)
• Providence Medicare Advantage Plan (PDF)
• Health Share of Oregon (Medicaid) (PDF)

Request for confidential communications for members of:

• Providence Health Plan (PDF) Oregon
• Providence Health Plan (PDF) Washington

Allow Providence Health Plans to share your protected health information with a third party for members of:

• Providence Health Plan (PDF)
• Providence Medicare Advantage Plan (PDF)
• Health Share of Oregon (Medicaid) (PDF)

• Transition of care request (PDF)

Most providers bill Providence Health Plan directly; however, if you must submit a medical claim to Providence, please use these forms: 

• Medical claim form (PDF) 
• Mental health/chemical dependency claim form (PDF)
  For Providence St. Joseph Health Southern California caregivers ONLY: please use this form for mental health/chemical dependency reimbursement (all dates of service).
  
  For ALL OTHER members: Use this form for mental health/chemical dependency reimbursements for dates of service on or before 12/31/2020. For services on or after 1/1/2021, use the Medical claim form (above).
• Alternative care claim form for providers (PDF)
• Medical travel reimbursement form (PDF)
• Transplant travel reimbursement form (PDF)
• COVID-19 at-home testing member reimbursement form (PDF)

Vision claim forms

• VSP reimbursement form (PDF)
  (Use when services are rendered by a non-VSP provider)
• Vision claim form  (PDF)
  (Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)

• Prescription drug reimbursement request form (PDF)
• Prescription drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)

• Medical home selection form (PDF)
• Formulario de Providence para la selección de hogar médico (PDF)

*Medical home selections only apply to Choice and Connect plan designs. If you’re unsure, please contact customer service.

• Providence Incident Questionnaire (PDF)

• Providence Other Medical Insurance Coverage (PDF)