Member forms

Member authorization and privacy forms

2018 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.

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

2019 open enrollment change form for individual and family insurance plans

To make changes to your current Providence Individual & Family Plan coverage for the 2019 plan year starting Jan. 1, 2019, use the links below. With this form, you can change your plan, add or remove dependents, or terminate your 2018 coverage effective Dec. 31, 2018. If you have a Marketplace policy, go to HealthCare.gov to make changes.

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