Text Size: Member Forms, Maps and Notices
Documents, forms and notices for Providence Health Plan 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.
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 (PDF) for members of small business health plans
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)
- Vision Claim Form (PDF)
- Alternative care claim form for providers (PDF)
- Mental health/chemical dependency claim form (PDF)
- International claim form (PEBB members) (PDF)
Pharmacy
Designated record set
Member Maps
- Home Health, Hospice and Home Infusion Map (PDF)
- Home Services Medical Equipment Provider Map (PDF)
- Orthotic and Prosthetic Provider Map - In Portland (PDF)
- Orthotic and Prosthetic Provider Map - Outside Portland (PDF)
- Providence Medical Group Map
Member notices
Providence RN
Medical Advice Line where you can call 24-hours a day, seven days a week.