Forms

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.

  • Medical claim form
    Member reimbursement form is for non-participating providers only
  • Extra Bucks Reimbursement Form
    • Use this reimbursement form for behavioral health, dental and vision claims that are covered by your High Deductible Health Plan but are not submitted directly to Providence. You do not need to submit a claim form for medical services; medical claims are sent directly to Providence for processing.

      For employees enrolled in an Intel HDHP option under the Intel Group Health Plan who have Extra Bucks≠, over the counter (“OTC”) medicines and drugs and menstrual care products may be reimbursed from Extra Bucks. Medical care OTC medicine and drug expenses and menstrual care products may not be reimbursed prior to your HDHP deductible being satisfied. Vision and dental OTC medicine and drug expenses may be reimbursed prior to satisfying your HDHP deductible.

      Please review the expense reimbursement requirements for Extra Bucks in the Pay Stock and Benefits Handbook, Chapter 6, subsection 6.11. This change is effective for expenses incurred January 1, 2020 and after.

    • Extra Bucks eligible expense list
  • Mental health and chemical dependency claim form
  • Prescription drug reimbursement request form
  • HIPAA authorization form


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).