Get Or Providence Health Plan Php-112d 2012-2025

Filling out the OR Providence Health Plan PHP-112D is an important process for individuals seeking Oregon continuation coverage. This guide provides clear instructions to help you complete the form accurately and submit it in a timely manner.

Follow the steps to complete the OR Providence Health Plan PHP-112D online

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. In Section 1, provide the qualifying individual information including last name, first name, middle initial, address, date of birth, gender, daytime phone, member ID number, group number, and marital status.
3. In Section 2, enter your social security number and specify your marital status by selecting the appropriate option.
4. Indicate your qualifying event by selecting the reason for the request for continuation coverage, ensuring the date of the event or eligibility is included.
5. If you or someone else applying for continuation coverage is covered by another group insurance, select ‘Yes’ or ‘No’ and provide the required details if applicable.
6. In Section 3, list all dependent family members who will continue coverage, including their last name, first name, middle initial, date of birth, gender, and relationship.
7. In Section 4, sign the form to acknowledge the accuracy of the information provided and understand the disclosure of health information policies.
8. Finally, ensure all information is correct, then save changes, download, print, or share the completed form as needed.

Complete your documentation online for a smoother experience.