Forms & benefit information

PEBB Statewide plan:

• 2025 Member Handbook (PDF)

PEBB Choice plan:

• 2025 Member Handbook (PDF)

2025 Statewide plan benefit summaries:

• PEBB Statewide plan (PDF)
• PEBB Statewide plan (Spanish) (PDF)
• PEBB Statewide +100 plan (PDF)
• PEBB Statewide +100 plan (Spanish) (PDF)
• PEBB Statewide prescription drug plan (PDF)
• PEBB Statewide prescription drug plan (Spanish) (PDF)
• PEBB Statewide plan (part-time) (PDF)
• PEBB Statewide plan (part-time) (Spanish) (PDF)
• PEBB Statewide +100 plan (part-time) (PDF)
• PEBB Statewide +100 plan (part-time) (Spanish) (PDF)
• PEBB Statewide prescription drug plan (part-time) (PDF)
• PEBB Statewide prescription drug plan (part-time) (Spanish) (PDF)

2025 Choice plan benefit summaries:

• Providence Choice plan (PDF)
• Providence Choice plan (Spanish) (PDF)
• Providence Choice +100 plan (PDF)
• Providence Choice +100 plan (Spanish) (PDF)
• Providence Choice prescription drug plan (PDF)
• Providence Choice prescription drug plan (Spanish) (PDF)
• Providence Choice plan (part-time) (PDF)
• Providence Choice plan (part-time) (Spanish) (PDF)
• Providence Choice +100 plan (part-time) (PDF)
• Providence Choice +100 plan (part-time) (Spanish) (PDF)
• Providence Choice prescription drug plan (part-time) (PDF)
• Providence Choice prescription drug plan (part-time) (Spanish) (PDF) 

Summaries of Benefits and Coverage, or SBCs, are required under the Affordable Care Act. The intent is to allow an “apples to apples” comparison of medical health plan benefits across carriers. For more information about SBCs, visit HealthCare.gov.

2025 PEBB Statewide plans SBCs:

• PEBB Statewide (PDF)
• PEBB Statewide (Spanish) (PDF)
• PEBB Statewide (part-time) (PDF)
• PEBB Statewide (part-time) (Spanish) (PDF)
• PEBB Statewide +100 (PDF)
• PEBB Statewide +100 (Spanish) (PDF)
• PEBB Statewide +100 (part-time) (PDF)
• PEBB Statewide +100 (part-time) (Spanish) (PDF)
  
  

2025 PEBB Choice plans SBCs:

• Providence Choice (PDF)
• PEBB Choice (Spanish) (PDF)
• Providence Choice (part-time) (PDF)
• PEBB Choice (part-time) (Spanish) (PDF)
• Providence Choice +100 (PDF)
• PEBB Choice +100 (Spanish) (PDF)
• Providence Choice +100 (part-time) (PDF)
• PEBB Choice +100 (part-time) (Spanish) (PDF)

Request access to your health plan records:

• Member Request to Access Protected Health Information (PDF)

Make changes to your health plan records:

• Member Request to Amend a Designated Record Set (PDF)

Restrict access to your health plan records:

• Member Request to Restrict Access to Designated Record Set (PDF)

Request for confidential communications:

• Request for Confidential Communication (PDF) Oregon

Allow Providence Health Plans to share your protected health information with a third party:

• Member Authorization Form (PDF)

• Transition of Care Request (PDF)

Most providers bill Providence Health Plan directly, however there may be times when you need to submit a medical claim to Providence. If so, please use these forms:

• Medical Claim Form (also for international claims) (PDF)
• Alternative Care Claim Form (for providers) (PDF)

• Prescription Drug Reimbursement Request Form (PDF)
• Prescription Drug Prior Authorization Form (PDF)

• PEBB Medical Home Selection Instruction Flyer (PDF)
• PEBB Medical Home Selection Instruction Flyer - Spanish (PDF)
• Providence Choice Medical Home Selection Form (PDF)
• Providence Choice Medical Home Selection Form - Spanish (PDF)

Members on Oregon health plans must choose a Primary Care Provider (PCP) for themselves and each covered dependent, due to Oregon Senate Bill 1529. This bill requires Oregon health plans, including Providence Health Plan, to assign a PCP to members who live in Oregon within 90 days of enrollment. *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”. 

• Travel Reimbursement Form (PDF)