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
  • Medical Travel Reimbursement form
  • Grievances and Appeals form