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Providence Health Plans - Electronic Application
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Application
Plan Benefits:
Optimum Plan | Value
Plan | Prime Plan | HSA Plan
Plan Rates:
Optimum Plan | Value
Plan | Prime Plan | HSA Plan
Call 800.884.2343 or 541.434.9613 if you would like
to apply electronically.
Tips for completing your application:
- Download the application for health insurance from
Providence
Health Plans of Oregon.
- Please read everything carefully and answer all
questions honestly. This document becomes part
of your health insurance contract.
- Please complete all sections to the best of your
ability. Please pay special attention to the health
history Section. By including the specific
details to questions you answered "yes"
to - the processing of your application will be expedited.
Be sure to include:
- The specific name and date of the diagnosis
or condition and correct spelling.
- The treatment(s) that were done, including the
last time you visited the doctor for this condition
and medications that were prescribed and medications
that are currently being taken.
- Final result refers to the status of the condition.
If it has been treated and your doctor has not
requested any follow-ups, please state so. If
you are still seeing the doctor, please state
so.
- Complete name, address and phone number of the
doctor.
- Provide Certificate of Creditable Coverage
(if available)
Please refer to Credit
for Prior Coverage Eligibility for more
information. Please note, if you do not have your
Certificate of Creditable Coverage at the time of
application, please submit your application anyway.
Credit for pre-existing condition waiting periods
will be credited upon receipt of your Certificate
of Creditable Coverage by Providence Health Plans
of Oregon.
- Payment Options:
Direct Bill: If accepted when
applying with an application either faxed or mailed
you will be notified by mail the status and given
additional billing options at that time. Do
not send a premium payment in with the application.
- Final check list before mailing:
- All sections completed?
- Copy of Insurance Card or Certificate of Credible
Coverage
- Signed and Dated
- Send all Enrollment Materials to:
CDA Insurance LLC
PO Box 26540
Eugene, OR 97402
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