Member forms

• Requesting access to your health plan records
• Changing and restricting access to your health plan records
• Request for Confidential Communications
• Allowing Providence Health Plan to share your protected health information

Individual and family insurance plan forms

2021 Oregon plans

Providence Individual & Family Plan Open Enrollment is closed.

If you have experienced a qualifying event, you may use the links below to make changes to your 2021 plan.

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.

• 2021 online change form for Individual and Family insurance
• 2021 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)
• 2021 rate calculator

2020 Oregon plans

If you have experienced a recent qualifying event, you may use the links below to make changes to your  2020 plan.

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.

• 2020 online change form for Individual and Family insurance
• 2020 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)
• 2020 rate calculator

2021 Washington plans

Providence Individual & Family Plan Open Enrollment is closed. 

If you have experienced a qualifying event, you may use the links below to make changes to your 2021 plan.

With this form, you can change your plan, add or remove dependents, or terminate your coverage. If you have a Washington Health Benefit Exchange policy, go to WaHealthPlanFinder.org to make changes.

• 2021 online change form for Individual and Family insurance
• 2021 fillable change form for Individual and Family insurance (PDF)
  (Use if you need to list more than four dependents.)
• 2021 rate calculator

2020 Washington plans

If you have experienced a qualifying event, you may enroll in a 2020 plan at WaHealthPlanFinder.org.

To make changes to your 2020 coverage, visit WaHealthPlanFinder.org.

• 2020 fillable change form for Individual and Family insurance (PDF)
• 2020 rate calculator

Transition of care

• Transition of care request (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) 
• Mental health/chemical dependency claim form (PDF)
  Use this form for mental health/chemical dependency reimbursements for dates of service on or before 12/31/2020. For services on or after 1/1/2021, use Medical claim form (above).
• Mental health/chemical dependency claim form (PDF)
  For Providence St. Joseph Caregivers ONLY, use this form for mental health/chemical dependency reimbursements (all dates of service).
• Alternative care claim form for providers (PDF)
• Medical travel reimbursement form (PDF)
• Transplant travel reimbursement form (PDF)
• 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)

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)
• Formulario de Providence para la selección de hogar médico (PDF)