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Producer Forms
- Commission Payment Direct Deposit Form (PDF)
Print out this form, complete it and fax it back to Providence via secure fax.
Oregon Large Group Forms
Authorization to Use/Disclose Protected Health Information
Continuation of Coverage
Dental Insurance
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
Transition of Care
- Transition of Care Form (PDF)
Washington Large Group Forms
Authorization to Use/Disclose Protected Health Information
Continuation of Coverage
Dental Insurance
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
Transition of Care
- Transition of Care Form (PDF)
Oregon Small Group Forms
- Annual Census Data (PDF)
- Annual Census Data (XLS)
- Enrollment/Change of Status/Waiver of Coverage (PDF)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF)
- MetLife Enrollment/Change of Status/Waiver (PDF)
- Master Contract Application (PDF)
- Out-of-Area Dependent Enrollment (PDF)
- Small Group Producer Check List (PDF)
- Providence Health Plans Small Group Enrollment Requirements (3 or fewer) (PDF)
- Providence Health Plans Small Group Enrollment Requirements (4-50) (PDF)
- Group Profile Form (DOC)
Authorization to Use/Disclose Protected Health Information
Continuation of Coverage
Dental Insurance
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
Tax Documentation
Transition of Care
- Transition of Care Form (PDF)
Washington Small Group Forms
- Annual Census Data (PDF)
- Enrollment/Change of Status/Waiver of Coverage (PDF)
- Enrollment/Change of Status/Waiver of Coverage - Spanish (PDF)
- Master Contract Application for groups effective through 1/1/09 or later (PDF)
- Out-of-Area Dependent Enrollment (PDF)
- Small Group Producer Check List (PDF)
- Providence Health Plans Small Group Enrollment Requirements (PDF)
Authorization to Use/Disclose Protected Health Information
Continuation of Coverage
Dental Insurance
Medicare Prescription Drug Disclosure Notices
Pharmacy Reimbursement
Tax Documentation
Transition of Care
- Transition of Care Form (PDF)
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PDF files, download free Adobe Acrobat Reader
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