Member forms & documents
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Claims
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)
For Southern California caregivers ONLY: please use this form for mental health/chemical dependency reimbursement (all dates of service).
For ALL OTHER members: 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)
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Member authorization & privacy forms
- 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)
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Pharmacy
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Transition of care