Medicare member forms & documents
Important note:
You may request to have printed 2024 EOCs, printed 2025 EOCs, Provider & Pharmacy Directories and/or Formularies mailed to your home. If you have any questions or need help, don’t hesitate to reach out to Customer Service. We’re here to help you in any way we can.
Medicare member forms
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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 (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.
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Member authorization forms
- 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
- Allow Providence Medicare Advantage Plans to share your protected health information with a third party - Russian (PDF)
- Prior Authorization form for physicians and enrollees (PDF)
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Pharmacy forms
- Coverage determination form (PDF) - updated 1/9/2023
- Direct Member Reimbursement Form (PDF)
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Privacy forms
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)
- Request access to your health plan records - Russian (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)
- Make changes to your health plan record - Russian (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)
- Restrict access to your health plan records - Russian (PDF)
Request for confidential communications - CA:
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Transition of care
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.
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Transplant travel reimbursement form
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Plan change forms
To enroll in a different Providence Medicare Advantage Plan follow the steps below:
- Print the change form:
- 2025 Clackamas, Multnomah, Washington, and Yamhill counties in Oregon (PDF)
- 2025 Columbia, Crook, Deschutes, Hood River, Jefferson, Lane, Marion, Polk, and Wheeler counties in Oregon and Clark county in Washington (PDF)
- 2025 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington (PDF)
- 2025 Benton, Franklin, Snohomish, Spokane, and Walla Walla counties in Washington - Spanish (PDF)
- 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon (PDF)
- 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Spanish (PDF)
- 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Vietnamese (PDF)
- 2025 Dual Plus (HMO D-SNP)/Clackamas, Multnomah and Washington counties in Oregon - Russian (PDF)
- Complete the form.
- 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
- Providence Medicare Advantage Plans
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.
- Print the change form:
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Over-the-counter (OTC) reimbursement form
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)
Evidence of Coverage and Annual Notice of Change documents for 2025 Providence Medicare Advantage plans
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For members who receive their coverage through a group or employer only plan
To view the Evidence of Coverage (EOC) or Summary of Benefits (SB) for your 2025 Providence Medicare Advantage Plan, please log in to your myProvidence account.
You can also request to have a printed EOC mailed to your home.
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Providence Medicare Bridge + Rx (HMO-POS)
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Providence Medicare Choice + Rx (HMO-POS)
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Providence Medicare Cottonwood + Rx (HMO-POS)
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Providence Medicare Dual Plus (HMO D-SNP)
- Dual Plus (HMO D-SNP) Evidence of Coverage (PDF)
- Dual Plus (HMO-D-SNP) Evidence of Coverage - Spanish (PDF)
- Dual Plus (HMO-D-SNP) Evidence of Coverage - Vietnamese (PDF)
- Dual Plus (HMO-D-SNP) Evidence of Coverage - Russian (PDF)
- Dual Plus (HMO D-SNP) Annual Notice of Change (PDF)
- Dual Plus (HMO D-SNP) Annual Notice of Change - Spanish (PDF)
- Dual Plus (HMO D-SNP) Annual Notice of Change - Vietnamese (PDF)
- Dual Plus (HMO D-SNP) Annual Notice of Change - Russian (PDF)
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Providence Medicare Extra + Rx (HMO)
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Providence Medicare Focus Medical (HMO)
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Providence Medicare Pine + Rx (HMO)
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Providence Medicare Prime + Rx (HMO)
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Providence Medicare Reverence (HMO-POS)
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Providence Medicare Sycamore + Rx (HMO)
- Sycamore + Rx (HMO) Evidence of Coverage (PDF)
- Sycamore + Rx (HMO) Evidence of Coverage - Spanish (PDF)
- Sycamore + Rx (HMO) Evidence of Coverage - Vietnamese (PDF)
- Sycamore + Rx (HMO) Annual Notice of Change (PDF)
- Sycamore + Rx (HMO) Annual Notice of Change - Spanish (PDF)
- Sycamore + Rx (HMO) Annual Notice of Change - Vietnamese (PDF)
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Providence Medicare Timber + Rx (HMO)
Evidence of Coverage and Annual Notice of Change documents for 2024 Providence Medicare Advantage plans
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For members who receive their coverage through a group or employer only plan
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.
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Providence Medicare Bridge + Rx (HMO-POS)
- 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
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Providence Medicare Choice + Rx (HMO-POS)
- 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
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Providence Medicare Cottonwood + Rx (HMO-POS)
- 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
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Providence Medicare Dual Plus (HMO D-SNP)
- 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
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Providence Medicare Extra + Rx (HMO)
- Extra + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
- Extra + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023
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Providence Medicare Focus Medical (HMO)
- Focus Medical (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
- Focus Medical (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023
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Providence Medicare Pine + Rx (HMO)
- 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
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Providence Medicare Prime + Rx (HMO)
- Prime + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
- Prime + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023
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Providence Medicare Reverence (HMO-POS)
- Reverence (HMO-POS) Evidence of Coverage (PDF) - Updated 11/27/2023
- Reverence (HMO-POS) Annual Notice of Change (PDF) - Updated 10/1/2023
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Providence Medicare Sycamore + Rx (HMO)
- 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
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Providence Medicare Timber + Rx (HMO)
- Timber + Rx (HMO) Evidence of Coverage (PDF) - Updated 10/11/2023
- Timber + Rx (HMO) Annual Notice of Change (PDF) - Updated 10/20/2023
Webpage current as of: 12/03/2024