Documents, forms and notices for Providence Health Plan members:
Vision claim forms:
- Authorization to use/disclose health information to a third party (PDF)
- Authorization for a third party to use/disclose health information to Providence Health Plan (for members of small business health plans with 1 to 50 employees) (PDF)
- 2015 application for individual and family insurance (PDF)
- 2015 plan change form (PDF)
- Policy change request (also for adding and/or removing dependents) (PDF)
- Policyholder change form (PDF)
- Transition of care form (PDF)
- Medical claim form (PDF)
Vision claim forms:
- VSP reimbursement form (PDF) (Use when services are rendered by a non-VSP provider)
- Vision claim form(PDF) (Use if you have a Vision $200, Vision $300 or Vision $400 plan administered by Providence Health Plan)
- Alternative care claim form for providers (PDF)
- Mental health/chemical dependency claim form (PDF)
- International claim form (PEBB members) (PDF)
- Member request for access to a designated record set (PDF)
- Member request to amend a designated record set (PDF)
- Medical Home Selection Form (PDF)
- Silverton Health Medical Home Selection Form (PDF)
- Silverton Health Medical Home List (PDF)
*all information provided on this site was retrieved from https://healthplans.providence.org/individuals-families/ and from a phone interview with an insurance customer service representative reached at 800-878-4445.