Providence Medicare Advantage Enrollment forms

Clackamas, Multnomah, Washington and Yamhill counties in Oregon

Columbia, Lane, Marion, Polk counties in Oregon and Clark County in Washington

Crook, Deschutes, Hood River, Jefferson and Wheeler counties in Oregon

Linn and Benton counties in Oregon

Spokane County in Washington

Snohomish County in Washington

DSNP area: Clackamas, Multnomah and Washington counties in Oregon

Medical Only No Rx area: Clackamas, Columbia, Lane, Marion, Multnomah, Polk, Washington, Yamhill counties in Oregon and Clark County in 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: