2021 Oregon plans

You may use the links below to make changes to your 2021 plan under the COVID-19 Special Enrollment Period, which runs from February 15, 2021 through August 15, 2021. You do not need to have experienced a qualifying event to make changes during this time.

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

• 2021 online change form for Individual and Family insurance
• 2021 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)

2021 Washington plans

Providence Individual & Family Plan Open Enrollment is closed. 

You may use the links below to make changes to your 2021 plan under the COVID-19 Special Enrollment Period, which runs from February 15, 2021 through August 15, 2021. You do not need to have experienced a qualifying event to make changes during this time.

With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Washington Health Benefits Exchange policy, go to WaHealthPlanFinder.org to make changes.

• 2021 online change form for Individual and Family insurance
• 2021 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 Medical claim form (above).
• Alternative care claim form for providers (PDF)
• Medical travel reimbursement form (PDF)
• Transplant travel 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.