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 to make changes.

Transition of care


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


Medical home selection

Health education reimbursement