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.
2018 change forms for individual and family insurance plans
For 2018 qualifying events only
The applications below are for new applicants with a 2018 qualifying event and for plan changes for members who have purchased direct from Providence or an agent. If you have 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.
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