Enrollment forms

Oregon and Southwest Washington


Optional supplemental benefit coverage for dental

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: