Member forms & documents

• Request access to your health plan records (PDF)
• Make changes to your health plan records for members (PDF)
• Restrict access to your health plan records for members (PDF)
• Request for confidential communications for Oregon members (PDF)
• Request for confidential communications for Washington members (PDF)
• Allow Providence Health Plans to share your protected health information with a third party for members (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)
  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)

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