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Access all the forms you need to enroll an Oregon or Washington large or small employer group.
Oregon Large Group Forms
- Enrollment/Change of Status/Waiver of Coverage (PDF 88 kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 100kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Washington Large Group Forms
- Enrollment/Change of Status/Waiver of Coverage (PDF 47kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Oregon Small Group Forms
- Annual Census Data (PDF 30kb)
- Annual Census Data (XLS 58kb)
- Enrollment/Change of Status/Waiver of Coverage (PDF 88kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- MetLife Enrollment/Change of Status/Waiver (PDF 188kb)
- Master Contract Application (PDF 95kb)
- Master Contract Application (PDF 38kb) - for 10/1/08 effective groups
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Small Group Producer Check List (PDF 32kb)
- Providence Health Plans Small Group Enrollment Requirements (3 or fewer) (PDF 28kb)
- Providence Health Plans Small Group Enrollment Requirements (4-50) (PDF 26kb)
- Enrollment Form Example (PDF 110kb)
- Group Profile Form (Word doc 106kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Tax Documentation
Washington Small Group Forms
- Annual Census Data (PDF 71kb)
- Enrollment/Change of Status/Waiver of Coverage (PDF 88kb)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF 74kb)
- Employee Roster (PDF 310kb)
- Master Contract Application (PDF 131kb)
- Out-of-Area Dependent Enrollment (PDF 125kb)
- Small Group Producer Check List (PDF 31kb)
- Providence Health Plans Small Group Enrollment Requirements (PDF 33kb)
- Enrollment Form Example (PDF 110kb)
Authorization to Use/Disclose Protected Health Information
- Release by a Third-Party to Providence Health Plans Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form (PDF 110kb)
- Release by Providence Health Plans to a Third-Party Form - Spanish (PDF 105kb)
Continuation of Coverage
- COBRA Continuation Election Form (PDF 140kb)
- State Continuation Election Form (PDF 135kb)
Dental Insurance
- Standard Insurance Company (PDF 721kb)
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
- Prescription Drug Reimbursement Request Form (PDF 124kb)
Tax Documentation
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