Providence Health Plan Individual & Family plan Open Enrollment Period is closed.

Current members that experience a qualifying event during the Special Enrollment Period, Jan. 1, 2024 - Dec. 31, 2024, can make changes to their plan using the forms below.

2024 Oregon Plans

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

 

If you have a Marketplace policy, please visit HealthCare.gov to make changes. 

• 2024 online change form for Individual & Family insurance
• 2024 fillable change form for Individual & Family insurance (PDF)
  (Use if you need to list more than six dependents)

2024 Washington Plans

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

 

• 2024 online change form for Individual & Family insurance
• 2024 fillable change form for Individual & 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)

Make changes to your health plan records for members of:

• Providence Health Plan (PDF)

Restrict access to your health plan records for members of:

• Providence Health Plan (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)

Our Care Management team is ready and available to assist you with things like transitioning from one health plan to another, finding and establishing with a new physical or behavioral health provider, coordination between providers, and much more.

Go to our transition of care page to learn more about all the support our team can provide and how to get started.

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)
• Gene therapy and adoptive cellular travel reimbursement form (PDF)
• Medical travel reimbursement form (PDF)
• OR Transplant Travel Reimbursement Form (PDF)
• WA 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 selections only apply to Choice and Connect plan designs. If you're unsure if this applies to your Providence Health Plan coverage, please contact customer service at 503-574-7500 or 800-878-4445 (TTY: 711). 

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

• Providence Incident Questionnaire (PDF)

• Providence Other Medical Insurance Coverage (PDF)