Member forms & documents

2026 Member Forms:

• Choice, Connect, HSA Enrollment Form (PDF)
• Choice, Connect, HSA Enrollment Form (Spanish) (PDF) *coming soon*

Master Group Application

Renewal Confirmation

2025 Member Forms:

• Choice, Connect, HSA Enrollment Form (PDF)
• Choice, Connect, HSA Enrollment Form (Spanish) (PDF) *coming soon*

Master Group Application

Renewal Confirmation

Authorization and Privacy Forms:

• Allow Providence Health Plans to share your protected health information with a third party for members (PDF)
• Medical Home Selection Form (English) (PDF)
• Medical Home Selection Form (Spanish) (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) 
• Alternative care claim form for providers (PDF)
• Medical travel reimbursement form (PDF)
• WA Transplant travel reimbursement form (PDF)
• OR Transplant travel reimbursement form (PDF)

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