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 (PDF)
• Medical claim form for Medicare members - Spanish (PDF)
• Medical claim form for Medicare members - Vietnamese (PDF)
• CMS appointment of representative form for Medicare members (PDF)
  (Medicare members must complete this authorization form when someone is submitting a member reimbursement request on their behalf)
• For Mental Health/Chemical Dependency, please use the medical claim form for Medicare members.

• Health education reimbursement form (PDF)

• Allow Providence Medicare Advantage Plans to share your protected health information with a third party (PDF) - updated 3/17/2023
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Spanish (PDF) - updated 3/17/2023
• Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Vietnamese (PDF) - updated 3/17/2023
• Prior Authorization form for physicians and enrollees (PDF)

• Coverage determination form (PDF) - updated 1/9/2023
• Direct Member Reimbursement Form (PDF) 

Request access to your health plan records:

• Request access to your health plan records (PDF)
• Request access to your health plan records - Spanish (PDF)
• Request access to your health plan records - Vietnamese (PDF)

Make changes to your health plan records:

• Make changes to your health plan record (PDF)
• Make changes to your health plan record - Spanish (PDF)
• Make changes to your health plan record - Vietnamese (PDF)

Restrict access to your health plan records:

• Restrict access to your health plan records (PDF)
• Restrict access to your health plan records - Spanish (PDF)
• Restrict access to your health plan records - Vietnamese (PDF)

Request for confidential communications - CA:

• California Request for Confidential Communication form (PDF)

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.

• Transplant travel reimbursement form (PDF)

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

 

1. Print the change form: 
   
   • 2024 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon(PDF) - Updated 10/1/2023
   • 2024 Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington (PDF) - Updated 10/1/2023
   • 2024 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington(PDF) - Updated 10/1/2023
   • 2024 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon(PDF) - Updated 10/1/2023)


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.

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 (PDF) 
OTC reimbursement form Spanish (PDF) 
OTC reimbursement form Vietnamese (PDF) 

To view the Evidence of Coverage (EOC) or Summary of Benefits (SB) for your 2024 Providence Medicare Advantage Plan, please log in to your myProvidence account.

You can also request to have a printed EOC mailed to your home.

• Bridge + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 10/11/23 
• Bridge + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 10/1/2023 

• Choice + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 10/11/2023
• Choice + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 10/1/2023 

• Cottonwood + Rx (HMO-POS) Evidence of Coverage (PDF) - Updated 10/11/2023
• Cottonwood + Rx (HMO-POS) Evidence of Coverage - Spanish (PDF) - Updated 10/30/2023
• Cottonwood + Rx (HMO-POS) Annual Notice of Change (PDF) - Updated 10/1/2023
• Cottonwood + Rx (HMO-POS) Annual Notice of Change - Spanish (PDF) - Updated 10/11/2023

• Dual Plus (HMO D-SNP) Evidence of Coverage (PDF) - Updated 11/3/2023
• Dual Plus (HMO D-SNP) Annual Notice of Change (PDF) - Updated 10/1/2023

• Extra + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Extra + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023

• Focus Medical (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Focus Medical (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023

• Pine + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Pine + Rx (HMO) Evidence of Coverage - Spanish (PDF) - Updated 10/30/2023
• Pine + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023
• Pine + Rx (HMO) Annual Notice of Change - Spanish (PDF) - Updated 10/20/2023

• Prime + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Prime + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023

• Reverence (HMO-POS) Evidence of Coverage (PDF) - Updated 11/27/2023
• Reverence (HMO-POS) Annual Notice of Change (PDF) - Updated 10/1/2023

• Sycamore + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Sycamore + Rx (HMO) Evidence of Coverage - Spanish (PDF) - Updated 10/30/2023
• Sycamore + Rx (HMO) Evidence of Coverage - Vietnamese (PDF) - Updated 10/30/2023
• Sycamore + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/11/2023
• Sycamore + Rx (HMO) Annual Notice of Change - Spanish (PDF) - Updated 10/11/2023
• Sycamore + Rx (HMO) Annual Notice of Change - Vietnamese (PDF) - Updated 10/11/2023

• Timber + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
• Timber + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023