Member forms

Request access to your health plan records for members of:

• Access your protected health information form (PHI) - English (PDF)
• Access your protected health information form (PHI) - Arabic (PDF) (coming soon)
• Access your protected health information form (PHI) - Chinese (PDF) (coming soon)
• Access your protected health information form (PHI) - Russian (PDF) (coming soon)
• Access your protected health information form (PHI) - Somali (PDF) (coming soon)
• Access your protected health information form (PHI) - Spanish (PDF) (coming soon)
• Access your protected health information form (PHI) - Vietnamese (PDF) (coming soon)

Make changes to your health plan records for members of:

• Change of Records Form - English (PDF)
• Change of Records Form - Arabic (PDF)
• Change of Records Form - Chinese (PDF)
• Change of Records Form - Russian (PDF) 
• Change of Records Form - Somali (PDF) 
• Change of Records Form - Spanish (PDF) 
• Change of Records Form - Vietnamese (PDF)

Restrict access to your health plan records for members of:

• Limit Access to Records Form - English (PDF)
• Limit Access to Records Form - Arabic (PDF) 
• Limit Access to Records Form - Chinese (PDF)
• Limit Access to Records Form - Russian (PDF)
• Limit Access to Records Form - Somali (PDF)
• Limit Access to Records Form - Spanish (PDF)
• Limit Access to Records Form - Vietnamese (PDF)

Allow Providence Health Assurance to share your protected health information with a third party for members of:

• Member Authorization Form - English (PDF)
• Member Authorization Form - Arabic (PDF) (coming soon)
• Member Authorization Form - Chinese (PDF) (coming soon)
• Member Authorization Form - Russian (PDF) (coming soon)
• Member Authorization Form - Somali (PDF) (coming soon)
• Member Authorization Form - Spanish (PDF) (coming soon)
• Member Authorization Form - Vietnamese (PDF) (coming soon)

Request for confidential communication endangerment:

If you believe receiving communications at your address could put you in danger, you have the right to request a confidential communication. You can make this request verbally by calling the number on your ID card.

Accounting for disclosures:

You have the right to request a list of certain disclosures of your health information made by Providence Health Assurance. You can make this request verbally by calling the number on your ID card.