Member forms

Consent and privacy forms

• Requesting access to your health plan records
• Changing and restricting access to your health plan records
• Request for Confidential Communications
• Allowing others to share your protected health information

Policy change request forms for individual and family insurance plans

The applications below are for new applicants and for plan changes for members who have purchased direct from Providence or an agent. If you have a Marketplace policy, or want to enroll in a Marketplace policy, please go to HealthCare.gov to make changes.

• 2018 application for individual and family insurance: Apply online
• 2018 application for individual and family insurance (PDF): Download and print a paper application

If your coverage is dependent only, or you need to list more than three children, use the paper application.

Transition of care

• Transition of care form (PDF)

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) 
• Medical claim form for Medicare members (PDF)
• CMS appointment of representative form for Medicare members (PDF) (Medicare members must complete this consent form when someone is submitting a member reimbursement request on their behalf)
• Vision claim forms
  • VSP reimbursement form (PDF) (Use when services are rendered by a non-VSP provider)
  •  Vision claim form (PDF) (Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)
• Alternative care claim form for providers (PDF)
• Mental health/chemical dependency claim form (PDF)
• Mental health/chemical dependency claim form for Medicare members (PDF)
• Medical travel reimbursement form (PDF)

Pharmacy

• Prescription drug reimbursement request form (PDF)
• Prescription drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)

Medical home selection

• Medical home selection form (PDF)
• Formulario de Providence para la selección de hogar médico (PDF)