Member forms

Member authorization and privacy forms

2019 change forms for individual and family insurance plans

To make changes to your current Providence Individual & Family Plan coverage for the 2019 plan year, use the links below. With this form, you can change your plan, add or remove dependents, or terminate your coverage. 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