Member forms

Documents, forms and notices for Providence Health Plan and Providence Health Assurance members. You may be able to fill some of these forms on your computer, then print, sign (if necessary) and submit via instructions on the form.

Consent and privacy forms

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.

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