Providence Medicare Advantage Plan enrollment forms & documents

Enrollment information

Please visit our how to enroll page and read the enrollment instructions before completing enrollment forms.

Once you have completed your enrollment form, fax it to 503-574-8653 or mail to:

Providence Medicare Advantage Plans

P.O. Box 5548
Portland, OR 97228-5548

You will receive a notice in the mail acknowledging receipt of your enrollment request.

Individuals must have both Part A and Part B to enroll.

Reference documents

• Multi-language insert (PDF) - Updated 4/26/23
• 2025 Summary of Benefits
• 2025 Benefit Highlights
• 2025 Enrollment Guides
• 2024 Summary of Benefits
• 2024 Benefit Highlights
• 2024 Enrollment Guides
• Evidence of Coverage and ANOCs
• Request provider and pharmacy information
• Pharmacy Resources
• Optional Supplemental Dental Benefits
• Plan star rating
  • English | Spanish | Vietnamese | Korean | Russian | Simplified Chinese
• Important contract information (PDF)
• How to appoint a representative (PDF)

Resources for enrollment

• How to enroll – Helpful information on when and where to enroll
• Premium payment options – Your choices for how to pay your monthly bill
• Premium assistance – You may qualify for extra help
• Medicare Service Area – Where our plans are offered
• Pre-Enrollment Checklist
  • English | Spanish | Vietnamese | Korean | Russian | Simplified Chinese

• Pharmacy Resources