Providence Medicare Advantage Plans Enrollment Request Form

This form should take about twenty minutes to finish. Please complete as directed. Required fields are shown with an asterisk (*).

Please contact Providence Medicare Advantage Plans if you need information in another language or format (Braille).

Plan Selection (Step 1 of 12)

Current step number 01 Remaning Step number 02 Remaning Step number 03 Remaning Step number 04 Remaning Step number 05 Remaning Step number 06 Remaning Step number 07 Remaning Step number 08 Remaning Step number 09 Remaning Step number 10 Remaning Step number 11 Remaning Step number 12

Welcome to the Providence Medicare Advantage Plans Enrollment Form. Completing this form will enroll you in Providence Medicare Advantage Plans.

*Please check which plan you want to enroll in:


Providence Health Plan is a health plan with a Medicare contract.

Y0085_PHP1324_CMS Approved 11062012

Webpage is current as of 10/15/2012

Contact Us:

Customer Service
503-574-8000 or
800-603-2340

Medicare Advantage Sales
503-574-5551 or
800-457-6064

TTY: 711
M-Sun, 8 am to 8 pm

Mailing Address