Online enrollment is no longer available for 2021 Individual and Family plans
The special enrollment period for 2021 individual and family plan coverage deadline was November 30, 2021; however, you can still apply for and get health insurance coverage if you experience an eligible retroactive qualifying life event. See the list below for qualifying life events that are eligible for a retroactive effective date.
Oregon and Washington policyholders may obtain coverage due to a special enrollment retroactive qualifying event by submitting an application for coverage.
Enrollment forms for Individual & Family plans
- 2021 Fillable application for Oregon individual and family insurance (PDF)
- 2021 Fillable application for Washington individual and family insurance (PDF)
- Birth, adoption, placement for adoption or foster care of a child
- Qualified Medical Child Support Order (QMCSO)
- Acquisition of legal guardianship
When the qualifying event is birth, adoption, placement or court order; coverage will be effective from the date of birth, adoption, placement or court order, provided your completed application and initial premium payment are received within 60 days of birth, adoption, placement or court order.
Please note: Our acceptance of premium is not a guarantee of coverage. Providence Health Plan can request proof of your qualifying event. If you enroll under special enrollment and later it is discovered you cannot prove the qualifying event, your coverage may be cancelled.
If your completed application is not received within 60 days of the special enrollment qualifying event, you will no longer be eligible for special enrollment.
Mail completed form to:
Providence Health Plan
P.O. Box 4649
Portland, OR 97208-4649
Fax completed form to:
2021 Plan Overviews
- 2021 Plan Overview (PDF)