Access all the forms you need to enroll an Oregon or Washington large or small employer group.
Oregon Large Group Forms
- Enrollment/Change of Status/Waiver of Coverage (PDF 77kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Washington Large Group Forms
- Enrollment/Change of Status/Waiver of Coverage (PDF 77kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Oregon Small Group Forms
- Annual Census Data (PDF 30kb)
- Annual Census Data (XLS 58kb)
- Enrollment/Change of Status/Waiver of Coverage (PDF 77kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- MetLife Enrollment/Change of Status/Waiver (PDF 188kb)
- Master Contract Application (PDF 95kb)
- Master Contract Application (PDF 38kb) - for 10/1/08 effective groups
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
- Group Profile Form (Word doc 106kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Tax Documentation
Washington Small Group Forms
- Annual Census Data (PDF 71kb)
- Enrollment/Change of Status/Waiver of Coverage (PDF 77kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- Employee Roster (PDF 310kb)
- Master Contract Application (PDF 94kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Tax Documentation
To view 
PDF files, download free Adobe Acrobat Reader
Providence Health in Business
Read our Employer newsletter editions to catch up on all your health news.