Oregon Application for
Individual & Family Insurance
www.ProvidenceHealthPlan.com
503- 574- 5000
800- 988- 0088
Thank you for choosing Providence Health Plan for your individual health insurance coverage. You can also compare plans,
check rates and apply on our website at www.ProvidenceHealthPlan.com.
Application instructions
Please PRINT clearly in black or blue ink and mail or fax your completed application and any necessary documentation to:
Providence Health Plan, P.O. Box 4649, Portland, OR 97208-4649
Fax: 503-574-8601
Do not include payment with this application.
Complete all sections of this application. Make sure to include your requested effective date (page 5) and home
address and phone number (page 2). If the application is incomplete or additional information is required, your effective date
may be delayed.
Please note: You will be notified by mail regarding the status of your application.
Important Information about Medicare:
Are you age 65 or over and entitled to Medicare?
Yes □ No □
Are you a Medicare Recipient due to disability or End Stage Renal Disease? Yes □ No □
If you answered “yes,” you may not be eligible to enroll in this plan. The federal government does not allow health plans to
issue Individual coverage that duplicates coverage available through Medicare.
If you need assistance, please contact your Agent or call the Providence Health Plan Sales Team at 503-574-5000
or 1-800-988-0088, TTY: 711.
Step1: Type of Application (choose one):
□ Open Enrollment Nov. 1, 2015 - Jan. 31, 2016
□ Qualifying Event during Special Enrollment Feb. 1, 2016 - Dec. 31, 2016
(see page 2 for examples and to indicate your event date)
For more information on qualifying events, visit www.ProvidenceHealthPlan.com, or call 503-574-5000 or 1-800-988-0088
□ For myself only
□ For my dependent(s) only
(Step 3A required)
You must be age 18 or older and reside in our Service Area.
(age 20 and younger) (Steps 3A and 3C required)
□ For myself and spouse/domestic
partner (Steps 3A & 3B required)
Policyholder must age 18 or older and parent or
legal guardian of the dependent. The
dependent(s) must reside in our Service Area.
Includes you and your spouse or domestic partner*. You both must
reside in our Service Area.
□ For myself and my family
Relationship to dependent(s):
(Steps 3A, 3B & 3C
required)
Includes you, your spouse or domestic partner* and dependent
children age 25 and younger. You and your spouse or domestic
partner must reside in our Service Area.
* A Domestic Partner must be a member of the applicant’s same sex, 18 years of age or older and must have legally registered a Declaration of Domestic
Partnership and obtained a Certificate of Registered Domestic Partnership in accordance with Oregon state law.
For Agent use only
(all fields are required)
I, (the agent) certify I have explained the eligibility provisions to the applicant. I have not made any statements about benefits, conditions
or limitations of the contract except through written material furnished by Providence Health Plan.
I have informed the applicant that the effective date of coverage is assigned only by Providence Health Plan and provided the Oregon
Disclosure Information required. I certify that the information supplied to me by the applicant has been truly and accurately recorded here.
Agent Name
Agency Name
PHP Agent Number
Agent E-mail
Phone Number
FAX Number
Date: Agent Signature
X
PIC-OR 0116 IND APP
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IND 015 Q
Step 2: Special Enrollment Qualifying Events
Complete this section only if you are applying outside of open enrollment Feb. 1, 2016 - Dec. 31, 2016
If you are applying outside of Open Enrollment due to a Special Enrollment Qualifying Event, you must complete your application
within 60 days of your qualifying event or your loss of coverage, whichever is later. Please indicate the date of your event in the
chart below. No effective dates prior to the date of application submission are allowed.
Qualifying Event
Submit application within 60 days
of the dates below
Acquired legal guardianship
Date of placement
Adoption, including placement for adoption
Date of adoption or placement
Birth
Baby's date of birth
Qualified Medical Child Support Order (QMCSO)
Date of issuance of Court Order
Death primary enrollee causing loss of coverage
Last day of coverage with other insurance
Date of event
Divorce or legal separation causing loss of coverage Last day of coverage with other insurance
Eligible for state premium assistance under a
Medicaid or CHIP program
First eligibility date
Exceed lifetime limit on medical plan
Last day of coverage with other insurance
Loss of coverage except for failure to pay the
premium
Last day of coverage with other insurance
Marriage or Registered Domestic Partnership
Date of Marriage or Registered Domestic
Partnership
No longer considered a dependent
Last day of coverage with other insurance
No longer residing or working in the service area
Date began full time residency in Oregon
Plan no longer offered
Last day of coverage with other insurance
Step 3: Enroll for coverage
Please PRINT CLEARLY and provide complete information. Incomplete information may delay your effective date.
3A Information for ! Primary Applicant or ! Dependent-only Policyholder
(age 18 and older) (Please fill out completely)
Applicant/ Policyholder Last Name
First Name
Middle Initial
Home Address (No Post Office Box)
City
State
Zip Code
County
Mailing Address (if different from Home Address)
City
State
Zip Code
County
Home/cell Phone Number (Required)
Work Phone/Other Phone Number
E-mail Address
Date of Birth (MM-DD-YYYY)
Age
Gender
Social Security Number
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial
purposes)?^
Yes # No #
PIC-OR 0116 IND APP
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3B Information for ! Spouse or ! Domestic Partner to be included in this policy
(Please fill out completely)
Spouse/Domestic Partner Last Name
First Name
Middle Initial
Home Address (No Post Office Box)
City
State
Zip Code
County
Mailing Address (if different from Home Address)
City
State
Zip Code
County
Home/cell Phone Number (Required)
Work Phone/Other Phone Number
E-mail Address
Date of Birth (MM-DD-YYYY)
Age
Gender
Social Security Number
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial
purposes)?^
Yes # No #
3C List additional Family Member(s) to be included in this policy
(Please include full, legal names. For a dependent-only policy, dependent(s) must be age 20 and younger. For all other policies, dependents
must be age 25 and younger)
Last Name
First Name,
Middle Initial
1. Dependent Child
Gender
Age
Social Security
Date of Birth
Number
(MM-DD-YYYY)
Residence
Zip Code
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial purposes)?^
Yes # No #
2. Dependent Child
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial purposes)?^
Yes # No #
3. Dependent Child
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial purposes)?^
Yes # No #
4. Dependent Child
" Male
" Female
Have you used any tobacco products an average of at least 4 times per week in the past 6 months (except for religious or ceremonial purposes)?^
Yes # No #
Please explain your relationship to any person listed above whose last name is different from the policyholder:
!If you have additional family members to be enrolled, please include them on a separate sheet with this application.
^ Tobacco use is defined as the use of tobacco products in any form an average of four or more times per week for the past six months.
Regular tobacco users may pay a different premium.
3D Billing Information if different from above
(Complete this section only if billing information should be sent to an address or person other than listed above.)
Name
Mailing Address 1
PIC-OR 0116 IND APP
Relationship to Applicant or Dependent
Mailing Address 2
City
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State
Zip Code
County
3E Address Information for dependent(s) in 3C on a dependent-only policy if
different from policyholder in 3A
(If your dependent child(ren) have more than one different address, please attach on a separate sheet)
Dependent child’s name
Dependent’s Home address (complete only if different from Policyholder)
City
State
Zip Code
County
Dependent’s Mailing address (complete only if different from Policyholder)
City
State
Zip Code
County
Home Phone/cell Number (Required)
Policyholder E-mail Address
Work Phone/Other Phone Number
Step 4: Choose a Medical Plan
Check
one
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Providence Individual
& Family Plans
Balance 1000 Gold
Balance 2000 Silver
Balance 4000 Silver
Balance 6800 Bronze
HSA Qualified 2800 Silver
HSA Qualified 6000 Bronze
Choice 1000 Gold
Choice 2000 Silver
Choice 4000 Silver
Choice 6800 Bronze
Connect 1000 Gold
Connect 2000 Silver
Connect 4000 Silver
Connect 6800 Bronze
Providence Oregon
Standard Gold
Providence Oregon
Standard Silver
Providence Oregon
Standard Bronze
Providence Essential*
Network
Deductible
Out-of-Pocket Maximum
Individual / Family
Individual / Family
(in-network)
(in-network)
Providence Signature Network
Providence Signature Network
Providence Signature Network
Providence Signature Network
Providence Signature Network
Providence Signature Network
Providence Choice Network
Providence Choice Network
Providence Choice Network
Providence Choice Network
Providence Connect Network
Providence Connect Network
Providence Connect Network
Providence Connect Network
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
$6,800/$13,600
$2,800/$5,600
$6,000/$12,000
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
$6,800/$13,600
$1,000/$2,000
$2,000/$4,000
$4,000/$8,000
$6,800/$13,600
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
$6,850/$13,700
$5,000/$10,000
$6,450/$12,900
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
$6,850/$13,700
$4,000/$8,000
$6,850/$13,700
$6,850/$13,700
$6,850/$13,700
Providence Signature Network
$1,250/$2,500
$6,350/$12,700
Providence Signature Network
$2,500/$5,000
$6,350/$12,700
Providence Signature Network
$5,000/$10,000
$6,350/$12,700
Providence Signature Network
$6,850/$13,700
$6,850/$13,700
* Available to people age 29 and younger only
**If you selected a Choice or Connect plan, you will need to choose a medical home and a primary
physician/provider upon enrollment. To see medical homes in your area, view our provider directory
at www.ProvidenceHealthPlan.com/directory
To review a summary of benefits and coverage (SBC) for these medical plans, visit
www.ProvidenceHealthPlan.com/sbc2016 or call our Sales team at 1-800-988-0088
Pediatric Dental Disclaimer: Some of our medical plan options DO NOT include pediatric dental coverage. Under
the health care reform law (the Affordable Care Act or ACA), if you purchase our medical coverage outside of the
Marketplace, we must have reasonable assurance that you have obtained separate pediatric dental coverage
through a Marketplace-certified pediatric dental plan. This requirement applies whether you obtain coverage for
children or adults. Marketplace-certified pediatric dental plans can be found through the Federal Health Insurance
Marketplace, www.HealthCare.gov.
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PIC-OR 0116 IND APP
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Step 5: Add dental coverage (optional)
Check to choose
dental
Dental Plan
Deductible
Individual / Family
(in-network)
Annual Maximum
Benefit
□
Providence Progressive Dental
$25/$75
$1,000
Our optional family dental plan provides benefits for adults and children for an additional monthly charge. In order to
purchase the Providence Progressive Dental Plan, you must also purchase a PHP medical plan.
If you apply for this dental plan, everyone enrolled in this application will be included under this dental plan. If anyone in
your family wishes to apply for a medical plan and no dental plan, please submit a separate medical plan application.
If you purchase a PHP Standard or Essential medical plan, adding the Providence Progressive Dental Plan for
children aged 18 and younger does not satisfy the ACA pediatric dental Essential Health Benefit (EHB)
requirement.
Step 6: Choose your effective date
Request your effective date of coverage: 1
st
□ or
15
th
□ of Month
2016
You must choose either the first or the fifteenth of the month for an effective date. Your effective date must be no more than
70 days after the signature date on this application.
If you are applying during Special Enrollment (see page 2), you must complete your application within 60 days of your
qualifying event or your loss of coverage, whichever is later.
If for any reason there is a delay in the application process, Providence Health Plan will move your requested effective date
forward to the next available date.
Payment information:
Your initial premium payment must be received prior to the effective date.
Please do not send a payment with this paper application. You will receive a letter with the following information:
confirmation of plan chosen; list of covered family members; and the amount and date of your first premium payment. You
may pay your initial premium by personal check or debit/credit card (Visa or MasterCard only). After the initial payment, you
will receive a monthly invoice from Providence Health Plan. Methods of payment include personal check, debit/credit card
(Visa or MasterCard only), auto-pay (sign up at www.Providence.org/billpay), or you may make payments using online bill pay
from your financial institution.
Step 7: Additional Information
1. Prior Providence Health Plan coverage
Have you or any family members listed on this application had Providence Health Plan coverage in the last five years?
□ Yes
□ No
1a. If Yes, list Member I.D. number(s):
2. Other Coverage
Do you or any family members listed on this application have current health or medical coverage, such as an Employer Group
plan (other than Providence Health Plan), Medicare, Social Security Disability, Tricare or other?
□ Yes
□ No
2a. If Yes, list name of insurance company:
Effective date of current medical coverage:
PIC-OR 0116 IND APP
Policy Number:
Termination date of current medical coverage
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3. Creditable Coverage
If you have had prior health insurance coverage and you are applying within 63 days of prior
coverage termination, you may be eligible for credit toward any exclusion period applicable
under our plan.
Do you or any family members listed on this application have a Certificate of Creditable Coverage?
□
Yes
□
No
3a. If Yes, please complete the Other Insurance Coverage information below and attach a copy of your Certificate
of Creditable Coverage with this application.
Other Insurance Coverage
Insurance Company (Full Name)
Insurance Company Phone Number
Address of Insurance Company
Type of Insurance coverage: □ Employer Group
□ Individual □ Medicare □ S.S. Disability □ Portability
□ Other: (Please list):
Policy and /or Member I.D. number(s)
#1
#2
#3
Name of Insured Family Member(s)
Date coverage started
Date coverage ends
#1
#2
#3
!If you have additional “Other Insurance Coverage Information,” please include on a separate sheet with this application.
4. How did you hear about Providence Health Plan?
□ Agent □ Friend/Family □ Direct Mail □ Online ad □ Social media □ Providence website □ TV □ Radio
□ Newspaper □ Billboard □ Other:
PIC-OR 0116 IND APP
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Step 8: Please Read, Sign & Submit
Certification
Certification Of Completion And Correctness
I affirm that the answers given in this Application for Coverage are complete and correct. I am providing these answers as
part of the application procedure required by Providence Health Plan (PHP) to enroll for insurance coverage. I understand
that if this application contains any intentional material misstatements or omissions, other than
misstatements or omissions related to the use of tobacco products, PHP may rescind, modify or
cancel the contract, and/or take any other legal action available to it by law. I will promptly
inform PHP in writing if anything happens before my coverage takes effect that makes this
application incomplete or incorrect. I understand and agree that no coverage shall be in force until the effective
date determined by PHP and that PHP may contact me to clarify answers on this application. As the applicant, I understand I
have the right to inspect the information in my file.
I understand that I can visit www.ProvidenceHealthPlan.com to educate myself about PHP’s privacy practices. I understand
that I can get a copy of PHP’s Notice of Privacy Practices by going to www.ProvidenceHealthPlan.com and selecting
“Privacy Notices & Policies” or by calling Customer Service.
Signature
1.
I understand that Providence Health Plan will:
a. notify me in writing as to the status of my application.
b. send me a legal contract upon enrollment.
2.
I am the parent or legal guardian of any dependent child listed on this application.
3.
I verify that my employer will not be paying the premium on this policy.
4.
I affirm that if I choose a medical plan without pediatric dental coverage, I will obtain pediatric dental coverage
through a separate Cover Oregon-certified pediatric dental plan, and that I will notify Providence Health Plan
if I do not obtain coverage.
By signing, I agree to the above conditions.
Signature of Applicant (or the Parent/Legal Guardian signature for a Dependent-Only application)
Relationship to dependent applicant under 18:
Date
X
Signature of Spouse or Domestic Partner*
□
X
Signed by applicant for spouse or domestic partner*
* The applicant may sign for a spouse or domestic partner. Please check the appropriate box above.
Before you submit this application, did you remember to:
! Include home address and phone number (Page 2)
! Select a medical plan (Page 4)
! Select an effective date (Page 5)
! Sign and date (Page 7)
PIC-OR 0116 IND APP
PIC-OR 0116 IND APP
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IND 015 Q