Member forms

Documents, forms and notices for Providence Health Plan and Providence Health Assurance members. You may be able to fill some of these forms on your computer, then print, sign (if necessary) and submit via instructions on the form.

Consent and privacy forms

Policy change request forms for individual and family insurance plans

  • 2016 policy change request form: to cancel a policy, add or remove dependents, or make other changes to an existing policy through Mar. 1, 2017 – allowing 60 days for newborns born on Dec. 31, 2016 (PDF)

Transition of care

Claims

Most providers bill Providence Health Plan directly; however, if you must submit a medical claim to Providence, please use these forms:

Pharmacy

Medical home selection

Health education reimbursement