This form should take about ten minutes to finish. Please complete as directed. Required fields are shown with an asterisk (*).
Please contact your Health Plan if you need information in another language or format (Braille).
Welcome to the Providence Request Form.
*Enrollee Name:
*Date of Birth(MM/DD/YYYY):
*Enrollee Member ID:
*Prescriber Name:
*Prescriber Phone Number(###)###-####:
*Who are you? I am the Enrollee I am the Prescriber I am the Enrollee's Personal Representative
*Phone Number(###)###-####:
Email Address:
Address:
Fax(###)###-####:
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.
*Requestor Name:
*Relationship to Enrollee:
*Requestor's Phone Number(###)###-####:
Requestor's Email Address:
