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
We've made it easy to get a rate quote for our health plans and enroll online.
Get a quote and enroll
Providence Health Plans Individual & Family plan Open Enrollment Period is closed.
New applicants that experience a qualifying event may enroll in a 2025 Individual & Family plan during a Special Enrollment Period, Jan. 1, 2025 - Dec. 31, 2025, using the enrollment forms below.Providence Health Plan must receive your completed enrollment application within 60 days of the qualifying event date.
2025 Oregon Residents
2025 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).