Member forms

Consent forms

• Authorization to use/disclose health information to a third party (PDF)
• Authorization for a third party to use/disclose health information to Providence Health Plan (for members of small business health plans with 1 to 50 employees) (PDF)

Application, plan selection and changes to existing coverage

• 2016 application for individual and family insurance (PDF)
• 2016 policyholder change form (PDF)
• 2016 individual and family plan change form (PDF)
• 2016 individual and family application change form

• Policy change request (also for adding and/or removing dependents) (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)
• International claim form (PEBB 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)

Designated record set

• Member request for access to a designated record set (PDF)
• Member request to amend a designated record set (PDF)

Medical home selection

• Medical home selection form (PDF)