Individual & Family forms
Access our enrollment forms or online application to get started. You can also find other health plan forms to help you navigate your health plan coverage.
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 here.
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2025 Individual & Family insurance enrollment forms
New applicants - get a quote and enroll today
Beginning November 1, 2024 - January 15, 2025, new applicants can apply online for Individual & Family coverage during the Open Enrollment Period.
Get a quote and enroll
New applicants can also apply for Individual & Family coverage during the Open Enrollment Period, beginning November 1, 2024, using the enrollment forms below.
2025 Oregon Residents
Enrollment forms received between Nov. 1, 2024 – Dec. 31, 2024 will become effective January 1, 2025.
Enrollment forms received between Jan. 1, 2025 – Jan. 15, 2025 will become effective February 1, 2025.
2025 Washington Residents
Enrollment forms received between Nov. 1, 2024 – Dec. 15, 2024 will become effective January 1, 2025.
Enrollment forms received between Dec. 16, 2024 – Jan. 15, 2025 will become effective February 1, 2025.
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.
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2024 Individual & Family insurance enrollment forms
New applicants
New applicants that experience a qualifying event between Jan. 1, 2024 - Dec. 31, 2024 may enroll in a 2024 Individual & Family plan during a Special Enrollment Period, using the enrollment forms below.
2024 Oregon Residents
2024 Washington Residents
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.
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Transition of care
Use the Transition of Care form when you experience a change of benefits and need assistance transitioning care for current or previous services received from a prior health plan.
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Claims and billing
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)
- 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.
Learn more -
Pharmacy
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Medical home selection
Medical home selections only apply to Choice and Connect plan designs. If you're unsure if this applies to your Providence Health Plan coverage, please contact customer service at 503-574-7500 or 800-878-4445 (TTY: 711).