Claims forms

Most providers bill the plan directly; however, if you must submit a medical claim to Providence, please use these forms:

Medical claim form for Medicare members

• English | Spanish | Vietnamese
• CMS appointment of representative form for Medicare members
  (Medicare members must complete this authorization form when someone is submitting a member reimbursement request on their behalf)

Note: for Mental Health/Chemical Dependency, please use the medical claim form for Medicare members.

Reimbursement forms

• Transplant travel reimbursement form

OTC reimbursement forms: some items may not show as covered at checkout. If you believe an item should be covered and you have paid for those items yourself, please complete the reimbursement form.

OTC reimbursement form:

• English | Spanish | Russian | Vietnamese 

Member authorization forms

Allow Providence Medicare Advantage Plans to share your protected health information with a third party:

• English | Spanish | Vietnamese | Russian
• Prior Authorization form for physicians and enrollees 

Privacy forms

Request access to your health plan records:

• English | Spanish | Vietnamese | Russian

Make changes to your health plan records:

• English | Spanish | Vietnamese | Russian

Restrict access to your health plan records:

• English | Spanish | Vietnamese | Russian

Request for confidential communications (California)

• California request for confidential communication form

Request for confidential communication endangerment:

If you believe receiving communications at your address could put you in danger, you have the right to request a confidential communication. You can make this request verbally by calling the number on your ID card.

Accounting for disclosures:

You have the right to request a list of certain disclosures of your health information made by Providence Health Assurance. You can make this request verbally by calling the number on your ID card.

To enroll in a different Providence Medicare Advantage Plan follow the steps below:

 

1. Print the change form: 
   

   2025 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon

   • English

   2025 Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington

   • English

   2025 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington 

   • English | Spanish

   2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon 

   • English | Spanish | Vietnamese | Russian
   
   
2. Complete the form.


3. Mail to Providence Medicare Advantage Plans at:
   
   
   • Providence Medicare Advantage Plans
     P.O. Box 5548
     Portland, OR 97228-5548
     provMedicare@providence.org
   • Or fax to 503-574-8607

You will receive a notice in the mail acknowledging receipt of the completed plan change or a request for additional information if the form is not complete.

To enroll in a different Providence Medicare Advantage Plan follow the steps below:

 

1. Print the change form: 
   

   2026 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon

   • English

   2026 Hood River and Lane counties in Oregon and Clark county in Washington 

   • English

   2026 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington 

   • English | Spanish

   2026 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon

   • English | Spanish | Vietnamese | Russian | Simplified Chinese | Arabic | Somali
   
   
2. Complete the form.


3. Mail to Providence Medicare Advantage Plans at:
   
   
   • Providence Medicare Advantage Plans
     P.O. Box 5548
     Portland, OR 97228-5548
     provMedicare@providence.org
   • Or fax to 503-574-8607

You will receive a notice in the mail acknowledging receipt of the completed plan change or a request for additional information if the form is not complete.

Our Care Management team is ready and available to assist you with things like transitioning from one health plan to another, finding and establishing with a new physical or behavioral health provider, coordination between providers, and much more.

Go to our transition of care page to learn more about all the support our team can provide and how to get started.

Online provider and pharmacy directory

Online Delta Dental directory

Portland Metro Expanded (Clackamas, Columbia, Hood River, Multnomah, Washington, and Yamhill counties in Oregon, and Clark County, Washington)
Plans include: Align Group Plan + Rx (HMO), Bridge + Rx (HMO-POS), Choice + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + Rx (HMO-POS), Extra + Rx (HMO), Flex Group Plan + Rx (HMO-POS), Focus Medical (HMO), Prime + Rx (HMO), Reverence (HMO-POS), Timber + Rx (HMO)

• English

Central Oregon (Crook, Deschutes, Jefferson, and Wheeler counties) 
Plans include: Align Group Plan + Rx (HMO), Bridge + Rx (HMO-POS), Choice + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + Rx (HMO-POS), Extra + Rx (HMO), Flex Group Plan + Rx (HMO-POS), Focus Medical (HMO), Reverence (HMO-POS), Timber + Rx (HMO)

• English

South Central Oregon (Benton, Lane, Linn, Marion, and Polk counties)
Plans include: Align Group Plan + Rx (HMO), Bridge + Rx (HMO-POS), Choice + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + Rx (HMO-POS), Extra + Rx (HMO), Flex Group Plan + Rx (HMO-POS), Focus Medical (HMO), Reverence (HMO-POS), Timber + Rx (HMO)

• English

Orange County, California
Includes plan: Sycamore  + Rx (HMO)

• English and Spanish | Vietnamese

Southeast Washington (Benton, Franklin, Spokane and Walla Walla counties)
Plans include: Align Group Plan + Rx (HMO), Cottonwood + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + (HMO-POS), Flex Group Plan + Rx (HMO-POS), Pine + Rx (HMO), Reverence (HMO-POS)

• English and Spanish

Snohomish Country Washington
Plans include: Align Group Plan + Rx (HMO), Cottonwood + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + Rx (HMO-POS), Flex Group Plan + (HMO-POS), Pine + Rx (HMO), Reverence (HMO-POS)

• English and Spanish

Providence Medicare Dual Plus (HMO D-SNP) (Clackamas, Multnomah and Washington counties in Oregon
Plans include: Align Group Plan + Rx (HMO), Cottonwood + Rx (HMO-POS), Discover Group Plan + Rx (HMO-POS), Explore Group Plan + Rx (HMO-POS), Flex Group Plan + (HMO-POS), Pine + Rx (HMO), Reverence (HMO-POS)

• English and Spanish | Vietnamese | Russian

• Delta Dental
  Oregon English | Oregon Spanish 
  Washington English | Washington Spanish

Request a provider and pharmacy listing:

If you are a current member and would like to have a provider listing mailed to you, please complete the form below. This listing contains providers and pharmacies located within 25 miles of where you live, so be sure to provide a physical address for best accuracy.

Members who live in rural areas may be provided with a listing of providers within a wider radius of their mailing address to ensure nearest provider and pharmacy information is included.

Request a local 2025 provider and pharmacy listing 

Request a full provider and pharmacy directory:

If you are a prospective member or current member and would prefer a complete directory that contains participating providers and pharmacies for entire plan areas in Oregon, Washington, and California, complete the form below

Request a full 2025 provider and pharmacy directory 

If you have questions about local provider listings, complete directories or the online directory, contact Customer Service at 503-574-8000 or 1-800-603-2340 TTY: 711 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

The pharmacy network may change at any time. You will receive notice when necessary.

Online provider and pharmacy directory

Online Delta Dental directory

Portland Metro Expanded – Clackamas, Columbia (group only), Hood River, Multnomah, Washington, and Yamhill counties; Clark County, Wash. 
Align Group Plan + Rx, Discover Group Plan + Rx, Extra + Rx, Flex Group Plan + Rx, Focus Medical, Prime + Rx, Reverence, Timber + Rx

• English

Providence Medicare Dual Plus (HMO D-SNP) – Clackamas, Multnomah and Washington counties in Oregon

• English & Spanish | Vietnamese | Russian | Simplified Chinese (Coming Soon) | Arabic (Coming Soon) | Somali (Coming Soon) 

Orange County, California
Sycamore + Rx

• English and Spanish | Vietnamese

Southeast Washington (Benton (WA), Franklin, Spokane, Walla Walla)
Align Group Plan + Rx, Discover Group Plan + Rx, Flex Group Plan + Rx, Pine + Rx, Reverence

• English and Spanish

Snohomish County, Washington
Align Group Plan + Rx, Discover Group Plan + Rx, Flex Group Plan + Rx, Pine + Rx, Reverence

• English and Spanish

South Central Oregon  – Lane County and group only in Benton, Linn, Marion and Polk counties
Align Group Plan + Rx, Discover Group Plan + Rx, Extra + Rx, Flex Group Plan + Rx, Focus Medical, Reverence, Timber + Rx

• English

Central Oregon – Group only in Crook, Deschutes, Jefferson and Wheeler counties
Align Group Plan + Rx, Discover Group Plan + Rx, Explore Group Plan + Rx, Flex Group Plan + Rx

• English

Delta Dental

• Oregon English (Coming soon) | Oregon Spanish (Coming soon)
• Washington English (Coming soon) | Washington Spanish (Coming soon)

Request a provider and pharmacy listing:

If you are a current member and would like to have a provider listing mailed to you, please complete the form below. This listing contains providers and pharmacies located within 25 miles of where you live, so be sure to provide a physical address for best accuracy.

Members who live in rural areas may be provided with a listing of providers within a wider radius of their mailing address to ensure nearest provider and pharmacy information is included.

Request a local 2026 provider and pharmacy listing 

Request a full provider and pharmacy directory:

If you are a prospective member or current member and would prefer a complete directory that contains participating providers and pharmacies for entire plan areas in Oregon, Washington, and California, complete the form below

Request a full 2026 provider and pharmacy directory 

If you have questions about local provider listings, complete directories or the online directory, contact Customer Service at 503-574-8000 or 1-800-603-2340 TTY: 711 8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st and Monday - Friday, April 1st through September 30th.

The pharmacy network may change at any time. You will receive notice when necessary.

Pharmacy Forms:

• Coverage determination form
• Direct Member Reimbursement Form

Formulary:

A formulary is your list of approved drugs. Click the link below to visit our Pharmacy Resources page to access our searchable database and PDFs to learn whether your prescription drug is covered by your plan

Formulary

Delta Dental of Oregon

Most plans offer $0 preventive dental like exams, cleanings, and x-rays with access to thousands of providers. Find a dentist in your area.

For routine dental benefit questions, please contact our dental Customer Service team.

1-833-212-5036 (TTY: 711)
8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st 
8 a.m. to 8 p.m. (Pacific Time) Monday - Friday, April 1st through September 30th

Attn: Providence Medicare Advantage 
P.O. Box 40384 
Portland, OR 97240

Optum: One Pass

With your One Pass™ fitness program, you can access over 17,000 gyms, change your fitness location anytime, and join live virtual classes at home or on-the-go.

youronepass.com
1-877-504-6830 (TTY: 711)
6 a.m. to 7 p.m. (Pacific Time) Monday – Friday

TruHearing

For hearing customer service, including predetermined benefits.

TruHearing.com/how-it-works
1-855-205-6201 (TTY: 711)
5 a.m. to 6 p.m. (Pacific Time), April 1 – September 30
5 a.m. to 8 p.m. (Pacific Time), October 1 – March 31 
Seven days a week

Health and Wellness Classes

From grief support to weight and pain management, we offer a host of classes that will enhance your life and broaden your horizons. 

Health and Wellness Classes
1-800-562-8964 (TTY: 711)
8:30 a.m. to 5 p.m. (Pacific Time)
Monday – Friday

Contact Customer Service to confirm benefit is included in your plan.
1-503-574-8000 or 1-800-603-2340 (TTY: 711)
8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st 
8 a.m. to 8 p.m. (Pacific Time) Monday - Friday, April 1st through September 30th 

Home Services

Contact Home Services for Durable Medical Equipment (DME) and related supplies.

Home Medical Equipment
1-800-762-1253
8 a.m. to 5 p.m.
Monday – Friday

Carelon Medical Benefits Management (Imaging)

Contact Carelon for imaging customer service, including imaging claims and predetermined benefits.

carelon.com 
1-800-920-1250 (TTY: 711)
8 a.m. to 8 p.m. (Pacific Time)
Seven days a week

Mom’s Meals (Meal delivery program)

After a hospital stay, Mom's Meals® will deliver ready-to-heat meals directly to your home (available on most plans).

Contact Providence’s Customer Service
503-574-8000 or 1-800-603-2340 (TTY 711)
8 a.m. to 8 p.m. (Pacific Time) 7 days a week, October 1st through March 31st 
8 a.m. to 8 p.m. (Pacific Time) Monday - Friday, April 1st through September 30th

Nurse Advice Line

Nurse Advice Line is available 24 hours a day, 7 days a week. Registered nurses will help you determine your next steps, from taking a pain reliever to visiting an urgent care location.

Oregon & Washington
503-574-6520 or 1-800-700-0481
24 hours a day, 7 days a week

California
1-800-809-3555
24 hours a day, 7 days a week

Connect America – Personal Emergency Response System (PERS)

A Personal Emergency Response System (PERS) gives you 24/7 access to help in the event of an emergency. Please call number below to sign up.

1-877-909-4882 
8 a.m. to 8 p.m. (Eastern Time), Monday through Friday. 

Over-the-Counter (OTC)

Some of our Medicare Advantage plans include funds to spend on over-the-counter items. Learn more.

Get a copy of your catalog or activate your card
Visit MyBenefitsCenter.com to view your balances

ConveyBenefits.com
1-855-858-5937
5 a.m. - 8 p.m. (Pacific Time)
Monday – Friday 

Quit for Life – Smoking Cessation

We cover the “Quit for Life” telephonic program, including program supplies like nicotine replacement therapy.

quitnow.net
1-866-784-8454 
8 a.m. to 5 p.m. (Pacific Time)
Monday – Friday

Kaizen Health – Non-medical transportation

As a D-SNP member, request non-medical transportation services.*

1-844-556-3730
5 a.m. to 6 p.m. (Pacific Time), Monday – Friday
7a.m. to 5p.m. (Pacific Time), Saturday
And open on holidays

*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.