Forms and Documents

Member Authorization & Privacy Forms

• PHI Authorization Form
• PHI Authorization Form (Spanish)
• Appointment of Authorized Representative
• Appointment of Authorized Representative (Spanish)
• Confidential Communication Request Form
• Restriction Request Form

Continuity of Care and Transition of Care Request

• Continuity of Care and Transition of Care Request Form

How to Submit a Claim

Most providers bill to Providence Health Plan Powered by Collective Health directly, however there may be times when you need to submit a medical claim.

To be reimbursed for health care services on or after January 1, 2026, you will need to submit a claim through your My Collective® online portal or mobile app using the following steps:

• Log in to your My Collective account: ProvidenceHealthPlan.CollectiveHealth.com
• At the top of the page, go to "Activity"
• Click "Submit a claim"

Need help? Call a Member Advocate at 855-346-5057, Monday - Friday, 4 a.m. to 6 p.m., and Saturday, from 7 a.m. to 11 a.m. (Pacific Time).

Extra Bucks Reimbursement Form

Members participating in the Extra Bucks Program can use the form below to submit claims for reimbursement.

• Extra Bucks Reimbursement Form

Pharmacy Forms

• Prescription Drug Reimbursement Request Form
• Prescription Drug Prior Authorization Form
• Uniform Prior Authorization Prescription Request Form

Network Gap Extension Requests

Gap exceptions address gaps in the medical network of contracted providers. Requesting a network gap exception from Providence Health Plan Powered by Collective Health is formally asking the health plan to cover care from an out-of-network provider at in-network cost-sharing rates.

• Network Gap Exception Request
• Network Gap Exception Request for Major Surgery

Learn more about network gap exceptions below.

• Understanding Gap Exceptions

Request for Internal Appeal and/or External Review

You have the right to review an internal appeal. This allows you to ask Providence Health Plan Powered by Collective Health to reconsider a decision about coverage or payment for medical services. They’ll review and may reverse their initial decision.

• Request for Internal Appeal Form
• Request for Internal Appeal Form (Spanish)

If Providence Health Plan Powered by Collective Health denies coverage or payment for medical services and you disagree with their decision, you can request an external review. This is done by an independent third party. They’ll review the situation and make a final decision.

• External Review Request Form