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  • Enrollment Request Form - Providence Health Plans - Healthplans Providence

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Effective Date of Coverage: ICEP/IEP: AEP: SEP (type): Not Eligible: Providence Medicare Advantage Plans Enrollment Request Form P.O. Box 5548 Portland, OR 97228 5548 PBP: Tran. Code: Plan #: Premiums:.

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Providence Health Plan serves more than 375,000 people, including individuals, families, commercial clients, and recipients of Medicaid and Medicare.

Complete a claim form. Attach a copy of receipt, provider invoice that includes the provider tax ID number, CPT codes, dates of service, ICD-10 codes (diagnosis codes), billed and paid amount with your proof of payment. Make a copy for your records.

Renton, WA Providence Health & Services / Headquarters

Payer Name: Providence Health Plan|Payer ID: PHP01|Professional (CMS1500)/Institutional (UB04)[Hospitals]

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232