Use this form to transfer your book of business to another agent or agency for all lines of business.

• Book of Business Transfer Form (PDF)

2025

• 2025 Oregon Individual & Family Creditable Coverage (PDF)
• 2025 Washington Individual & Family Creditable Coverage (PDF)
• 2025 Employer Group Creditable Coverage

2024

• 2024 Oregon Individual & Family Creditable Coverage (PDF)
• 2024 Washington Individual & Family Creditable Coverage (PDF)
• 2024 Employer Group Creditable Coverage

Oregon small groups

Choose your small group plan:

2025

• 2025 Total Enhanced, Balance, Standard, HSA Qualified plans (PDF)
• 2025 Connect or Choice plans (PDF)
• 2025 Total Enhanced, Balance, Standard, HSA Qualified plans (Spanish) (PDF)
• 2025 Connect or Choice plans (Spanish) (PDF)

2024

• 2024 Total Enhanced, Balance, Standard, HSA Qualified plans (PDF)
• 2024 Connect or Choice plans (PDF)
• 2024 Total Enhanced, Balance, Standard, HSA Qualified plans (Spanish) (PDF)
• 2024 Connect or Choice plans (Spanish) (PDF)

Oregon large groups

Choose your large group plan:

2025

• 2025 Choice, Connect or HSA Connect plans (PDF)
• 2025 Choice, Connect, or HSA Connect plans (Spanish) (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)

2024

• 2024 Choice, Connect or HSA Connect plans (PDF)
• 2024 Choice, Connect, or HSA Connect plans (Spanish) (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)

Washington large groups

Choose your large group plan:

2025

• 2025 Choice plans (PDF)
• 2025 Choice plans (Spanish) (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2025 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)

2024

• 2024 Choice plans (PDF)
• 2024 Choice plans (Spanish) (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (PDF)
• 2024 Option Advantage Base, Option Advantage Plus, Option Advantage Premium, Personal Option or Integrated HSA plans (Spanish) (PDF)

2025

• 2025 Small Group Statewide Enrollment Kit
  For use when Connect is not purchased. Packaged together in a single PDF, the Statewide enrollment kit contains all the forms you’ll need for Oregon Small Group enrollment: the master contract application, Oregon group size determination (GSD) form, enrollment/change of status/waiver form, and underwriting guidelines.
• 2025 Small Group Connect/Choice Enrollment Kit
  Packaged together in a single PDF, the Connect enrollment kit contains all the forms you’ll need for Oregon Small Group enrollment: the master contract application, Oregon group size determination (GSD) form, Connect enrollment/change of status/waiver form, medical home selection form and underwriting guidelines.
• 2025 Master Contract Application (PDF)
• 2025 Producer Checklist for Small Group Enrollment (PDF)
• 2025 Small Group Underwriting Guidelines
• 2025 Oregon Standardized Group Size Determination Form (PDF)
• SHOP Participation Request Form (PDF)

2024

• 2024 Small Group Statewide Enrollment Kit
  For use when Connect is not purchased. Packaged together in a single PDF, the Statewide enrollment kit contains all the forms you’ll need for Oregon Small Group enrollment: the master contract application, Oregon group size determination (GSD) form, enrollment/change of status/waiver form, and underwriting guidelines.
• 2024 Small Group Connect/Choice Enrollment Kit
  Packaged together in a single PDF, the Connect enrollment kit contains all the forms you’ll need for Oregon Small Group enrollment: the master contract application, Oregon group size determination (GSD) form, Connect enrollment/change of status/waiver form, medical home selection form and underwriting guidelines.
• 2024 Master Contract Application (PDF)
• 2024 Producer Checklist for Small Group Enrollment (PDF)
• 2024 Small Group Underwriting Guidelines
• 2024 Oregon Standardized Group Size Determination Form (PDF)
• SHOP Participation Request Form (PDF)

2025 plans

• For groups sized 1-50

2024 plans

• For groups sized 1-50

*For businesses with 51+ employees: We create unique benefit packages to meet the specific needs of each of our large group employers and their employees. Please contact your producer or account manager for more details.

For employer groups with 1-50 employees

• 2025 small group producer toolkit (PDF)
• 2024 small group producer toolkit (PDF)

For employer groups with 51+ employees

• 2025 large group producer toolkit (PDF)
• 2024 large group producer toolkit (PDF)

2025

• 2025 fillable application for Oregon Individual & Family insurance (PDF)
• 2025 fillable application for Washington Individual & Family insurance (PDF)

2024

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

Assist your client in making changes to their plan.

Current members can make changes to their policy during the Open Enrollment Period, Nov. 1, 2024 – Jan. 15, 2025. 

2025 Oregon Plans

With the forms below, your client can change their plan, add or remove dependents, or terminate their coverage.

If your client has a policy through Federal Health Insurance Marketplace policy, please visit HealthCare.gov to help them make changes. 

• 2025 fillable change form for Individual & Family insurance (PDF)

2025 Washington Plans

With the forms below, your client can change their plan, add or remove dependents, or terminate their coverage.

• 2025 fillable change form for Individual & Family insurance (PDF)

Current members that experience a qualifying event during the Special Enrollment Period, Jan. 1 - Dec. 31, 2024, can make changes to their plan using the forms below.

2024 Oregon Plans

• 2024 fillable change form for Individual & Family insurance (PDF)

2024 Washington Plans

• 2024 fillable change form for Individual & Family insurance (PDF)

• Scope of appointment (PDF)
• Scope of appointment (Spanish) (PDF)
• Scope of appointment (Vietnamese) (PDF)
• Producer home visit checklist (PDF)
• Medicare plan rating (PDF)
• Medicare plan rating (Spanish) (PDF)
• Medicare plan rating (Vietnamese) (PDF)

Medicare Plan Change Forms

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

1. Print the change form:


• Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF) (coming soon)
• Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington (PDF) (coming soon)
• Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington (PDF) (coming soon)
• Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon (PDF) (coming soon)


2. Complete the form


3. Mail to Providence Medicare Advantage Plans at:
• Providence Medicare Advantage Plans
  P.O. Box 5548
  Portland, OR 97228-5548
• Or fax to 503-574-8653

Clackamas, Multnomah, Washington and Yamhill counties in Oregon

• Benefit Highlights (coming soon)

Dual-eligible (DSNP): Clackamas, Multnomah, and Washington counties in Oregon

• Benefit Highlights (coming soon)

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

• Benefit Highlights (coming soon)

Benton and Linn counties in Oregon

• Benefit Highlights (coming soon)

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

• Benefit Highlights (coming soon)

Orange County in California

• Benefit Highlights (coming soon)

Medical Only Plans: Clackamas, Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Multnomah, Polk, Washington, Wheeler, and Yamhill counties in Oregon and Clark County in Washington

• Benefit Highlights (coming soon)

Medical Only: Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington

• Benefit Highlights (coming soon)

Use the following forms to manage authorization and access to your clients' health plan records and to request confidential communications. Have questions? Contact Customer Service for help: 503-574-7500, Monday through Friday, 8 a.m. to 5 p.m.

Providence Health Plan

• Request access to your health plan records (PDF)
• Make changes to your health plan records (PDF)
• Restrict access to your health plan records (PDF)
• Request for Confidential Communications - Oregon (PDF)

Member authorization forms:

• Allow Providence Health Plans to share your protected health information with a third party (PDF)

Providence Medicare Advantage Plan

• Request access to your health plan records (PDF)
• Make Changes to your health plan records (PDF) 
• Restrict access to your health plan records (PDF)

Member authorization forms:

• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF) 

Health Share of Oregon (Medicaid)

• Request access to your health plan records (PDF)
• Making changes to your health plan records (PDF)
• Restrict access to your health plan records (PDF)
• Allow someone else to access your health plan records (PDF)

• Out-of-area dependent enrollment (PDF)
• Transition of care (PDF)
• Other member forms and notices
• Medical home selection form (PDF)
• Medical home selection form - Spanish (PDF)
• Enrollment spreadsheet (ZIP)
• Implementation checklist - HRA (PDF)
• Implementation checklist - HSA (PDF)
• Implementation checklist - FSA (PDF)
• Employer Assistance Program Implementation form (PDF)
• Health Savings Account Authorization form (PDF)
• Book of Business Transfer Form (PDF)

PDF provider directory listings

• Provider directory (Providence Signature Network, Providence Choice Network and Providence Connect Network) (PDF)
• Health Share/Providence (OHP) (PDF)
• Providence Medicare Advantage Plans Provider & Pharmacy directories

If you need help or would like a Providence Health Plan provider directory mailed to you, please contact our customer service team at 503-574-7500 or 800-878-4445 Monday through Friday, 8 a.m. to 5 p.m. (Pacific time).

Online provider directory

The online provider directory contains a current listing of participating providers, facilities and pharmacies.

• Search the online provider directory

• Consolidated secret shopping tool (PDF)
• Private individual marketing appointment secret shopping tools (PDF)
• Public event secret shopping tool (PDF)

The Medicare & Continuation group size questionnaire is used to determine if Medicare pays primary or secondary to your group health plan coverage. It is also used to determine continuation of coverage.

• Annual group size questionnaire (PDF)