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Enrollment Request Form - Providence Health Plans - Healthplans Providence
Get Enrollment Request Form - Providence Health Plans - Healthplans Providence
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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EFT FAQ
Payer Name: Providence Health Plan|Payer ID: PHP01|Professional (CMS1500)/Institutional (UB04)[Hospitals]
Renton, WA Providence Health & Services / Headquarters
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.
Providence Health Plan serves more than 375,000 people, including individuals, families, commercial clients, and recipients of Medicaid and Medicare.
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