Member forms

Consent and privacy forms

• 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

• 2017 policy change request form: to cancel a policy, add or remove dependents, or make other changes to an existing policy (PDF)
• 2017 plan change form: to change to a plan with reduced benefits (once per year) (PDF)

• 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

• 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)