Producer Resource Hub

Employer

Individuals & Families

Enrollment Applications

New applicants that experience a qualifying event have a Special Enrollment Period and can apply using the enrollment forms below.

Plan change forms

Current members that experience a qualifying event have a Special Enrollment Period and can make changes to their plan using the forms below.

With the form below, your client can change their plan, add or remove dependents, or terminate their coverage.

If your client has a policy through the Health Insurance Marketplace®, please visit HealthCare.gov to help them make changes.

2026

• 2026 Oregon Small Group Statewide Enrollment Kit
  For use when neither Choice nor Connect are purchased. Packaged together in a single PDF, the Standard 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.
• 2026 Oregon Small Group Connect/Choice Enrollment Kit
  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.
• 2026 Oregon Master Contract Application (PDF)
• 2026 Oregon Producer Checklist for Small Group Enrollment (PDF)
• 2026 Oregon Small Group Guidelines (PDF)
• 2026 Oregon Standardized Group Size Determination Form (PDF)
• Oregon SHOP Participation Request Form (PDF)

2025

• 2025 Oregon Small Group Statewide Enrollment Kit
  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.
• 2025 Oregon Small Group Connect/Choice Enrollment Kit
  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.
• 2025 Oregon Master Contract Application (PDF)
• 2025 Oregon Producer Checklist for Small Group Enrollment (PDF)
• 2025 Small Group Underwriting Guidelines (PDF)
• 2025 Oregon Standardized Group Size Determination Form (PDF)
• Oregon SHOP Participation Request Form (PDF)

2026 Small Group

• 2026 Oregon plans for groups sized 1-50

2025 Small Group

• 2025 Oregon plans for groups sized 1-50

Large groups (51+)

We create unique benefit packages to meet the specific needs of each of our large group employers and their employees. Please contact your producer or account manager for more details.

Medicare Advantage

• Providence Medicare Dual Plus (HMO D-SNP)
  English | Spanish | Vietnamese | Russian | Simplified Chinese | Arabic | Somali
• Providence Medicare Extra + Rx (HMO)
• Providence Medicare Pine + Rx (HMO)
  English | Spanish
• Providence Medicare Prime + Rx (HMO)
• Providence Medicare Reverence (HMO-POS)
• Providence Medicare Focus (HMO)
• Providence Medicare Sycamore + Rx (HMO)
  English | Spanish | Vietnamese
• Providence Medicare Timber + Rx (HMO)

Medicare Supplement

• Medicare Supplement Plan A (PDF)
• Medicare Supplement Plan G (PDF)
• Medicare Supplement Plan N (PDF)

Individual & Family

• View Individual & Family Benefit Summaries and Summary of Benefits & Coverage (SBC)

Employer

Medicare

Individual & Family

2026 Oregon

• Providence Connect plans (PDF)
• Providence HSA Qualified Choice Network plan (PDF)
• Providence HSA Qualified Signature Network plan (PDF)
• Providence Oregon Direct Choice Network plan (PDF)
• Providence Oregon Direct Signature Network plan (PDF)
• Providence Oregon Standard Choice Network plans (PDF)
• Providence Oregon Standard Signature Network plans (PDF)
• Individual & Family Dental Plan (PDF)

2026 Washington

• Columbia Plans (PDF)

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)
• Making changes to your health plan records (PDF)
• Restrict access to your health plan records (PDF)
• Allow Providence Health Plans to share your protected health information with a third party (PDF)

• Request for Confidential Communications - Oregon (PDF)

• Request for Confidential Communications - Washington (PDF)

• Request for Confidential Communications - California (PDF)

Providence Medicare Advantage Plan

• Request access to your health plan records (PDF)
• Making changes to your health plan records (PDF)
• Restrict access to your health plan records (PDF)
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF)

Health Share of Oregon (Medicaid)

• Request access to your health plan records (PDF)
• Making changes to your health plan records (PDF)
• Restrict access to your health plan records (PDF)
• Allow someone else to access your health plan records (PDF)

The Medicare & Continuation 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.

Annual group size questionnaire (PDF)

• 2026 Medicare Advantage Enrollment Guides
• 2026 Medicare Advantage Benefit Highlights
• Medicare Supplement Outline of Coverage
• Optional Buy-up Dental Benefit Highlight

• Search the online provider directory

• Provider directory (Providence Signature Network, Providence Choice Network and Providence Connect Network) (PDF)

• Health Share/Providence (OHP) (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).

• Transition of care (PDF)
• Other member forms and notices

• Out-of-area dependent enrollment (PDF)

• Enrollment spreadsheet (ZIP)
• Medical home selection form (PDF)
• Medical home selection form - Spanish (PDF)
• Employer Assistance Program Implementation form (PDF)

• Consolidated secret shopping tool (PDF)
• Private individual marketing appointment secret shopping tools (PDF)
• Public event secret shopping tool (PDF)

Use this form to transfer your book of business to another agent or agency for all lines of business.

Book of Business Transfer Form (PDF)

• 2026 Employer Group Creditable Coverage (PDF)

• 2026 Oregon Individual & Family Creditable Coverage (PDF)

• 2026 Washington Individual & Family Creditable Coverage (PDF)

• 2025 Employer Group Creditable Coverage (PDF)

• 2026 Small Group producer toolkit (PDF)

• 2026 Large Group producer toolkit (PDF)

Scope of appointment

• English | Spanish | Vietnamese | Korean | Russian | Simplified Chinese | Arabic | Somali

Home visit checklist

• Producer home visit checklist (PDF)

Medicare plan ratings forms

• Medicare plan rating (PDF)
• Medicare plan rating (Spanish) (PDF)
• Medicare plan rating (Vietnamese) (PDF)

Medicare plan change forms

To enroll your client in a different Providence Advantage Plan follow the steps below:

1. Print the change form


2. Complete the form


3. Mail to Providence Medicare Advantage Plans at:
   
   • Providence Medicare Advantage Plans
     P.O. Box 5548
     Portland, OR 97228-5548
   • provMedicare@providence.org
   • Or fax to 503-574-8653

• Medicare Supplement Rate Sheet (PDF)

• 2026 Oregon Rate Sheet (PDF)

• 2026 Washington Rate Sheet (PDF)