, mail to Providence Health Plan, P.O. Box 4649,. Portland, OR 9
Individual and Family Plans
Plan Selection Form Instructions and Information ! You may choose a new Providence Individual & Family Plan during the open enrollment period. To change to a new medical plan, or to add dental coverage, you must complete and submit this form by email, mail or fax.
! If we approve your request, the effective date of the plan change will be the first of the month following receipt of this form. Please select one of the following effective dates:
! For coverage effective 1/1/16, this form must be received no later than 12/31/15 ! For coverage effective 2/1/16, this form must be received no later than 1/31/16 ! Email completed form to
[email protected], mail to Providence Health Plan, P.O. Box 4649, Portland, OR 97208-4649 or fax to 503-574-8601.
! Please note: Does not apply to plans purchased through the Federal Health Insurance Marketplace. Contact the marketplace at www.HealthCare.gov or 800-318-2596.
Step 1: Verify your information Please enter policyholder information (The policyholder is the person who holds the Individual contract) Policyholder Name
Policyholder member I.D. number
Mailing Address 1
Address 2
City
State
Zip Code
Home Phone Number
Work Phone/Other Phone Number
E-mail Address
County
Step 2: Select your new medical plan choice Please visit www.ProvidenceHealthPlan.com for plan details. Balance Plans
! Balance 1000
HSA Plans
! HSA
Choice Plans
Connect Plans
Catastrophic Plan
Standard Plans
! Choice 1000
! Connect
! Providence Oregon
! Providence
Gold
1000 Gold
Standard Gold 1250
Essential* 6850
! Choice 2000
! Connect
! Providence Oregon
Silver
2000 Silver
Standard Silver 2500
! Balance 4000
! Choice 4000
! Connect
! Providence Oregon
Silver ! Balance 6800 Bronze
Silver ! Choice 6800 Bronze
4000 Silver ! Connect 6800 Bronze
Standard Bronze 5000
Gold
! Balance 2000 Silver
Qualified 2800 Silver ! HSA Qualified 6000 Bronze
*Available to people age 29 and younger only
Step 3: Add Providence Progressive Dental Plan (optional) Please visit www.ProvidenceHealthPlan.com for plan details.
! Add the dental plan to my medical policy. The dental plan cannot be added after 1/31/16. Our optional family dental plan provides benefits for adults and children for an additional monthly charge. In order to add the Providence Progressive Dental Plan, you must also currently be on a Providence Health Plan medical plan. If you choose the dental plan, everyone enrolled in this policy will be included under this dental plan. If anyone in your family wishes to have a medical plan and not add the dental plan, visit www.ProvidenceHealthPlan.com/forms and complete the Policyholder Change form or contact Membership Accounting at 888-816-1300 for details. 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. IND-034E
1
Step 4: Provide information on Tobacco Usage Has any person on this application used tobacco products in any form on an average of four or more times per week within the last 6 months? Yes___ No___ If Yes: Name _________________________________________ Type of product ________________________________________ Name _________________________________________ Type of product ________________________________________ Name _________________________________________ Type of product ________________________________________
Step 5: Read the Certification and Authorization Certification Statement I affirm that I am requesting a change in coverage for myself and my enrolled family dependents and that the answers given in this Plan Selection Form are complete and correct. I am providing these answers as part of the procedure required by Providence Health Plan (PHP) to request a change in my insurance coverage. I will promptly inform PHP in writing if anything happens before my coverage takes effect that makes this change request incomplete or incorrect. I understand and agree that no change in coverage shall be in force until the effective date determined by PHP and that PHP may contact me to clarify this request. As the policyholder, I understand I have the right to inspect the information in my file. Authorization for the Release and Use and Disclosure of Personal Health Information I authorize any physician, healthcare provider, hospital, insurance or reinsurance company, or other insurance information exchange service to disclose to Providence Health Plan (PHP) or its representatives personal health information relating to me and/or any family members included in this Plan Change Form. Furthermore, I agree to sign any additional forms related to release of personal health information, as needed by PHP to obtain this information. I acknowledge and understand that the health information released to PHP: " Will only be used for the purpose of determining enrollment in health plan coverage or eligibility for benefits; " May include claims records, correspondence, medical records, billing statements, diagnostic imaging reports, laboratory reports, medication records, dental records, or hospital records (including nursing records and progress notes); and " May address all medical and mental health conditions and services, including HIV treatment, but shall exclude psychotherapy notes and genetic information. I understand that I may cancel this authorization at any time by sending a written request to PHP. My cancellation of this authorization will not affect any action PHP took before it received my request. If I do not revoke this authorization, it will automatically expire upon termination of my coverage with PHP. I understand that if I choose not to sign this authorization that PHP will be unable to process my selection of coverage. In addition, I understand that PHP may request and disclose personal health information, other than psychotherapy notes, for the purpose of: (a) performing the health plan business operations of PHP; (b) facilitating health care treatment; (c) issuing or facilitating payment for health care services; or (d) as required by law. The disclosure of psychotherapy notes by PHP is restricted to circumstances in which the patient has provided a signed authorization. For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the Notice of Privacy Practices. A copy is available at our website at www.ProvidenceHealthPlan.com or by calling Customer Service at 503-574-7500 or 1-800-878-4445, TTY: 711.
Step 6: Sign and Submit Acceptance of plan change procedure 1. I understand that Providence Health Plan will notify me in writing as to the status of my selection request. 2. I am the policyholder, and am requesting this selection for myself and my enrolled family dependents. 3. By signing, I agree to the above conditions. Date
Signature of Policyholder
X _______________________________________________________ Please email, mail or fax your completed Plan Selection Form by the dates referenced on other side of this form to:
[email protected], Providence Health Plan, P.O. Box 4649, Portland, OR 97208-4649 or Fax: 503-574-8601
IND-034E
2
