Individual & Family forms

To view, fill out and print the forms on this page, you will need the latest version of Adobe Acrobat Reader, which can be downloaded. However, Adobe Acrobat Reader does not allow you to save your completed, or partially completed, forms to your computer. For that expanded capability you will need to have the complete Adobe Acrobat software package, version 5.0 or later.

2024 Individual & Family insurance enrollment forms

New applicants - Get a quote

We’ve made it easy to view plan options and get a quote for our health plans. New applicants can get a quote and enroll online by clicking the button below.
Get a quote and enroll

Providence Health Plan Individual & Family plan Open Enrollment Period is closed.
New applicants that experience a qualifying event may enroll in a 2024 Individual & Family plan during a Special Enrollment Period, Jan. 1, 2024 - Dec. 31, 2024, using the enrollment forms below.

2024 Oregon Residents

• 2024 fillable application for Oregon Individual & Family insurance (PDF)

2024 Washington Residents

• 2024 fillable application for Washington Individual & Family insurance (PDF)

Please mail your completed application to:

Providence Health Plan
P.O. Box 4649
Portland, OR 97208-4649

Need assistance?

For help with choosing an Individual & Family plan, please contact our sales team at 503-574-5000 or 800-988-0088 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time), Monday through Friday.

Transition of care

• Transition of care request (PDF)

Claims and billing

• Medical claim form (PDF)
• Alternative care claim form (PDF)
  (Please have your provider complete the Alternative Care Claim Form)
• Medical travel reimbursement form (PDF)
• Oregon transplant travel reimbursement form (PDF)
• Washington transplant travel reimbursement form (PDF)
• Gene therapy and adoptive cellular travel reimbursement form (PDF)

Vision claim form

• VSP reimbursement form (PDF)
  (Use when services are rendered by a non-VSP provider)

For more information

Visit our claims and billing page to learn more about how we handle our processes.

Pharmacy

• Prescription drug reimbursement request form (PDF)
• Prescription drug prior authorization form (PDF)
• Uniform prior authorization prescription request form (PDF)

Medical home selection

• Medical home selection form (PDF)
• Formulario de Providence para la selección de hogar médico (PDF)