Member forms & documents

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 - Dec. 31, 2025, can make changes to their plan using the forms below.

 

Providence Health Plan must receive your completed enrollment application within 60 days of the qualifying event date.

2025 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. 

• 2025 online change form for Individual & Family insurance
• 2025 fillable change form for Individual & Family insurance (PDF)
  (Use if you need to list more than six dependents)

2025 Washington Plans

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

  

• 2025 online change form for Individual & Family insurance
• 2025 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)

Request for confidential communication endangerment:

If you believe receiving communications at your address could put you in danger, you have the right to request a confidential communication. You can make this request verbally by calling the number on your ID card.

Accounting for disclosures:

You have the right to request a list of certain disclosures of your health information made by Providence Health Assurance. You can make this request verbally by calling the number on your ID card.

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)

Members on Oregon based health plans must choose a Primary Care Provider (PCP) for themselves and each covered dependent, or have one assigned within 90 days of enrollment. This is due to Oregon Senate Bill 1529, which requires Oregon health plans to assign PCPs to members who live in Oregon. *This applies to all plans except Choice and Connect.

 

For more information on SB1529 visit, ProvidenceHealthPlan.com/SB1529

 

Primary Care Provider selection form (PDF)

Formulario de selección de profesional médico de cabecera (PDF)

 

NOTE: You can also login to your myProvidence account to select a PCP directly. Go to “PCP Selection” under the “My Providers” drop down in the top navigation bar. Use the search criteria to see PCP options. Then “Select” the PCP of your choice and hit “Accept”. 

• Providence Incident Questionnaire (PDF)

• Providence Other Medical Insurance Coverage (PDF)