Skip to guide content
Carrier Agreements

Providence Health Plan Application Agreement

Certification of Completion and Correctness I affirm that the answers given in this Application for Coverage are complete and correct. I am providing these answers as part of the application procedure required by Providence Health Plan (PHP) to enroll for insurance coverage. I understand that if this application contains any intentional material misstatements or omissions, other than misstatements or omissions related to the use of tobacco products, PHP may rescind, modify or cancel the contract, and/or take any other legal action available to it by law. I will promptly inform PHP in writing if anything happens before my coverage takes effect that makes this application incomplete or incorrect. I understand and agree that no coverage shall be in force until the effective date determined by PHP and that PHP may contact me to clarify answers on this application. As the applicant, I understand I have the right to inspect the information in my file. I understand that I can visit ProvidenceHealthPlan.com to educate myself about PHP’s privacy practices. I understand that I can get a copy of PHP’s Notice of Privacy Practices by going to ProvidenceHealthPlan.com and selecting “Notice of Privacy Practice” or by calling Customer Service at 503-574-7500.

Signature

  1. I understand that this is an individual health insurance contract and I verify that neither my employer nor any third party will be paying the premium on this policy except as permitted by state or federal regulation.

  2. I verify that I am not enrolled in Medicare. (The federal government does not allow health plans to issue Individual coverage that duplicates coverage available through Medicare.)

  3. I am the parent or legal guardian of all dependent children listed on this application.

  4. I verify that the home address I provided on this application for myself is accurate, as well as any other address provided by me for any dependents included on this application.

  5. I understand that I must update my information with Providence Health Plan if anything changes and is different than what I wrote on this application.

  6. I affirm that if I choose a medical plan without pediatric dental coverage, I will obtain pediatric dental coverage through a separate Marketplace-certified pediatric dental plan, and that I will notify Providence Health Plan if I do not obtain coverage.

  7. I understand that:

a. Providence Health Plan will send me an offer of coverage, containing terms for initial premium payment. b. I need to pay my initial premium payment by the due date specified on my offer of coverage to effectuate my policy. c. After my policy has been effectuated, Providence Health Plan will send me a legal contract.

  1. I understand that this application does not terminate other coverage through the Federal Marketplace, Providence Health Plan or other carriers.