Request for a Prescription Drug Prior Authorization

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

Please contact Providence Health Plan if you need information in another language or format (Braille).

Enrollee Information (Step 1 of 6)

Welcome to the Providence Request Form.

NOTE: You must provide documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form or a written equivalent). One of these documents is required in order to process this request. If an electronic version is not available, please contact the Pharmacy Team at (503) 574-7400 or 1-877-216-3644 or fax to (503) 574-8646 or 1-800-249-7714.