Intel Connected Care forms and information:

Most providers bill Providence Health Plan directly. In some cases, however, you may need to submit a request for reimbursement to Providence. If so, please use the forms on this page. Complete and submit the form following the instructions on the sheet.

Forms Instructions

Medical claim form

Providence Health Plan member reimbursement form for medical claims

Mental health and chemical dependency claim form

Most providers will submit a claim for mental health or chemical dependency care services to PBH on your behalf. There are some instances, however, when a physician or other medical provider does not submit a claim on your behalf, and you are responsible for paying for health care services in full at the time you receive them.

Prescription drug reimbursement request form

Providence Health Plan requires members to use participating pharmacies to access prescription drug benefits. As a member of the Plan, you have access to participating pharmacies nationwide. This Prescription Drug Reimbursement Request form is for use in exceptional circumstances when you are unable to access your prescription drug benefit,(e.g. Emergencies).

Providence Health Plan HIPAA authorization form

Use this form to authorize access to protected personal health information.