Member Forms

Here is a selection of the most commonly requested forms for PEBB members. You may be able to fill in some of these forms on your computer, then print, sign (if necessary) and submit the completed form following the instructions on the form.

Transition of care

Medical home selection


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:


Health engagement model (HEM)