Current members that experience a qualifying event during the Special Enrollment Period, Jan. 1 - Dec. 31, 2023, can make changes to their plan using the forms below.

2023 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, please visit HealthCare.gov to make changes.

• 2023 online change form for Individual and Family insurance
• 2023 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than six dependents)

2023 Washington Plans

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

• 2023 online change form for Individual and Family insurance
• 2023 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than six dependents)

Request access to your health plan records for members of:

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

Make changes to your health plan records for members of:

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

Restrict access to your health plan records for members of:

• Providence Health 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)
• Health Share of Oregon (Medicaid) (PDF)

Use the Transition of Care form when you experience a change of benefits and need assistance transitioning care for current or previous services received from a prior health plan.

• 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) 
• Alternative care claim form (PDF)
  (Please have your provider complete the Alternative Care Claim Form)
• Medical travel reimbursement form (PDF)
• OR Transplant Travel Reimbursement Form (PDF)
• WA 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 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)