Member forms

  • Member authorization & privacy forms

    Request access to your health plan records for members of:




    Make changes to your health plan records for members of:

    Restrict access to your health plan records for members of:

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




    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.