Member Forms & 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 Form

Authorization to Use/Disclose Health Information (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 this form:

Medical Claim Form (PDF)

Pharmacy

Prescription Drug Reimbursement Request Form (PDF)
Prescription Drug Prior Authorization Form (PDF)

Designated Record Set

Member Request for Access to a Designated Record Set (PDF)
Member Request to Amend a Designated Record Set (PDF)

Member Notices

Privacy Notices & Policies
Member Rights & Responsibilities

Members Toolkit

myProvidence
Provider Directory
Health Balance^® News
Member Forms
Providence RN

TruVision

Discounts on eye examinations, laser vision correction, and more.