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Enrollment forms for all groups
Medicare forms
- Scope of appointment (PDF)
Continuation of coverage forms
Health information disclosure forms for all groups
Dental insurance information for all groups
Oregon small-group forms
- Oregon enrollment kit (PDF)
Packaged together in a single PDF, here are the small-group producer checklist, master contract application, annual census form, enrollment/change of status/waiver form, proof-of-employment documentation and small-group requirements and limitations you’ll need for Oregon small-group enrollment. - Small-group producer check list (PDF)
- Group profile form (DOC)
- Annual census data (PDF)
- Annual census data (XLS)
- Authorization for a third party to use/disclose health information to Providence Health Plan (PDF)
- Master contract application (PDF)
- Small-group requirements and limitations (PDF)
- Tax documentation for Oregon SEHI groups
- Proof-of-employment documentation (PDF)
Washington small-group forms
- Washington enrollment kit (PDF)
Packaged together in a single PDF, here are the small-group producer checklist, master contract application, annual census form, enrollment/change of status/waiver form, proof-of-employment documentation and small-group requirements and limitations you’ll need for Washington small-group enrollment. - Small-group producer check list (PDF)
- Annual census data (PDF)
- Master contract application (PDF)
- Proof-of-employment documentation (PDF)
- Small-group requirements and limitations (PDF)
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Alternative Care
Discounts on acupuncture, chiropractic care, massage therapy and more.