Forms & documents
To view, fill out and print the forms on this page, you will need the latest version of Adobe Acrobat Reader, which can be downloaded here. However, Adobe Acrobat Reader does not allow you to save your completed, or partially completed, forms to a disk or on your computer. For that expanded capability you will need to have the complete Adobe Acrobat software package, version 5.0 or later.
-
Book of Business transfers
Use this form to transfer your book of business to another agent or agency for all lines of business.
-
Creditable Coverage
2023
- 2023 Oregon Individual & Family Creditable Coverage (PDF)
- 2023 Washington Individual & Family Creditable Coverage (PDF)
- 2023 Employer Group Creditable Coverage
2022
- 2022 Oregon Individual & Family Creditable Coverage (PDF)
- 2022 Washington Individual & Family Creditable Coverage (PDF)
- 2022 Employer Group Creditable Coverage
-
Employer enrollment/change of status/waiver of coverage forms
Oregon small groups
Choose your small group plan:
2023
- 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
- 2023 Connect or Choice plans (PDF)
- 2023 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (Spanish) (PDF)
- 2023 Connect or Choice plans (Spanish) (PDF)
2022
- 2022 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (PDF)
- 2022 Connect or Choice plans (PDF)
- 2022 Total Enhanced, Balance, Standard, HSA, or HSA Qualified plans (Spanish) (PDF)
- 2022 Connect or Choice plans (Spanish) (PDF)
Oregon large groups
Choose your large group plan:
2023
- 2023 Choice, Connect or HSA Connect plans (PDF)
- 2023 Choice, Connect, or HSA Connect plans (Spanish) (PDF)
- 2023 Option Advantage, HSA, or Personal Option plans (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)
2022
- 2022 Choice, Connect, or HSA Connect plans (PDF)
- 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2022 Choice, Connect, or HSA Connect plans (Spanish) (PDF)
- 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)
Washington groups
2023
- 2023 Choice plans (PDF)
- 2023 Choice plans (Spanish) (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2023 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)
2022
- 2022 Choice plans (PDF)
- 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
- 2022 Choice plans (Spanish) (PDF)
- 2022 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)
-
Oregon small group forms
2023
- 2023 small group Statewide enrollment kit (PDF)
For use when Connect is not purchased. Packaged together in a single PDF, the Statewide enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, enrollment/change of status/waiver form, and underwriting guidelines. - 2023 small group Connect/Choice enrollment kit (PDF)
Packaged together in a single PDF, the Connect enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, Connect enrollment/change of status/waiver form, medical home selection form and underwriting guidelines. - 2023 master contract application (PDF)
- 2023 producer checklist for small group enrollment (PDF)
- 2023 small group underwriting guidelines (PDF)
- 2023 Oregon standardized group size determination form (PDF)
- SHOP Participation Request Form (PDF)
2022
- 2022 small group Statewide enrollment kit (PDF)
For use when Connect is not purchased. Packaged together in a single PDF, the Statewide enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, enrollment/change of status/waiver form, and underwriting guidelines. - 2022 small group Connect/Choice enrollment kit (PDF)
Packaged together in a single PDF, the Connect enrollment kit contains all the forms you’ll need for Oregon small group enrollment: the master contract application, Oregon group size determination (GSD) form, Connect enrollment/change of status/waiver form, medical home selection form and underwriting guidelines. - 2022 master contract application (PDF)
- 2022 producer checklist for small group enrollment (PDF)
- 2022 small group underwriting guidelines (PDF)
- 2022 Oregon standardized group size determination form (PDF)
- SHOP Participation Request Form(PDF)
- 2023 small group Statewide enrollment kit (PDF)
-
Employer benefit summaries
2023 plans
2022 plans
-
Employer groups producer toolkits
For employer groups with 1-50 employees
For employer groups with 51+ employees
-
Enrollment forms for Individual & Family plans
-
Change forms for Individual & Family plans
Assist your client in making changes to their 2023 plan.
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, your client can change their plan, add or remove dependents, or terminate their coverage. If they have a Federal Health Insurance Marketplace policy, please visit HealthCare.gov to help them make changes.
2023 Washington Plans
With this form, your client can change their plan, add or remove dependents, or terminate their coverage.
-
Medicare forms
- Appointment for agent of record (PDF Coming soon)
- Scope of appointment (PDF)
- Scope of appointment (Spanish) (PDF)
- Scope of appointment (Vietnamese) (PDF)
- Producer home visit checklist (PDF Coming soon)
- Medicare plan rating (PDF)
- Medicare plan rating (Spanish) (PDF)
- Medicare plan rating (Vietnamese) (PDF)
2023 Medicare Plan Change Forms
To enroll your client in a different Providence Advantage Plan follow the steps below:
- Print the change form:
- Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF)
- Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington. (PDF)
- Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington. (PDF)
- Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon (PDF)
- Complete the form
- Mail to Providence Medicare Advantage Plans at:
- Providence Medicare Advantage Plans
P.O. Box 5548
Portland, OR 97228-5548 - Or fax to 503-574-8653
-
Medicare plan comparisons and enrollment guides
2023
Service Area 1: Clackamas, Multnomah, Washington and Yamhill counties in Oregon
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
Service Area 2: Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, Wheeler counties in Oregon and Clark County in Washington
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
Service Area 3: Benton and Linn counties in Oregon
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
Service Area 4: Benton, Franklin, Snohomish, Spokane, Walla Walla counties in Washington
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
- Enrollment Guide (Spanish) – updated 3/9/2023
Service Area 5: Orange County in California
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
- Enrollment Guide (Spanish) – updated 3/9/2023
- Enrollment Guide (Vietnamese) – updated 3/9/2023
Medical Only Plans: Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Multnomah, Polk, Washington, Wheeler, and Yamhill counties in Oregon and Clark County in Washington
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
Medical Only: Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
Dual-eligible (DSNP): Clackamas, Multnomah, and Washington counties in Oregon
- Plan Comparison
- Enrollment Guide – updated 3/9/2023
-
Health information and disclosure forms for all lines of business
Use the following forms to manage authorization and access to your clients' health plan records and to request confidential communications. Have questions? Contact Customer Service for help: 503-574-7500, Monday through Friday, 8 a.m. to 5 p.m.
Providence Health Plan
- Request access to your health plan records (PDF)
- Make changes to your health plan records (PDF)
- Restrict access to your health plan records (PDF)
- Request for Confidential Communications - Oregon (PDF)
Member authorization forms:
Providence Medicare Advantage Plan
- Request access to your health plan records (PDF)
- Make Changes to your health plan records (PDF)
- Restrict access to your health plan records (PDF)
Member authorization forms:
Health Share of Oregon (Medicaid)
-
Forms for all lines of business
- Out-of-area dependent enrollment (PDF)
- Transition of care (PDF)
- Other member forms and notices
- Medical home selection form (PDF)
- Medical home selection form - Spanish (PDF)
- Enrollment spreadsheet (ZIP)
- Implementation checklist - HRA (PDF)
- Implementation checklist - HSA (PDF)
- Implementation checklist - FSA (PDF)
- Employer Assistance Program Implementation form (PDF)
- Health Savings Account Authorization form (PDF)
- Book of Business Transfer Form (PDF)
-
Provider directories
PDF provider directory listings
- Provider directory (Providence Signature Network, Providence Choice Network and Providence Connect Network) (PDF)
- Health Share/Providence (OHP) (PDF)
- Providence MCO provider directory (PDF)
- Providence Medicare Advantage Plans Provider & Pharmacy directories
If you need help or would like a Providence Health Plan provider directory mailed to you, please contact our customer service team at 503-574-7500 or 800-878-4445 Monday through Friday, 8 a.m. to 5 p.m. (Pacific time).
Online provider directory
The online provider directory contains a current listing of participating providers, facilities and pharmacies.
-
Secret shopper surveillance tools
-
Group size questionnaire
The group size questionnaire is used to determine if Medicare pays primary or secondary to your group health plan coverage. It is also used to determine continuation of coverage.
Producers
Can’t find what you’re looking for?
Our sales team is here to help you find the resources you need to guide your clients to the plan that best fits their needs.
Get in touch