Enrollment forms

Oregon and Southwest Washington


Optional supplemental benefit coverage for dental and vision

Please read enrollment instructions before completing enrollment forms.

Complete the enrollment form and fax it to 503-574-8653 or mail to:

Providence Medicare Advantage Plans
P.O. Box 5548
Portland, OR 97228-5548

You will receive a notice in the mail acknowledging receipt of your enrollment request.

Individuals must have both Part A and Part B to enroll.

Reference documents: