Form Enr-008b - Out-Of-Area Benefits For Dependents Template - Providence Health Plan

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Out-of-Area Benefits for Dependents
Providence Health Plan offers an Out-of-Area benefit for Dependent Members (please refer to your Member Handbook
for “Dependent” and “Out-of-Area Dependent” definitions and eligibility requirements). Enrolled Out-of-Area
Dependents are eligible to receive routine care and other covered benefits while in or out of the service area. When
enrolled as an Out-of-Area Dependent, coverage is as stated on the Out-of-Area Dependent Summary of Benefits and
based on the Usual, Customary and Reasonable (UCR) charges for both in and out-of-area services. Amounts charged in
excess of UCR are the responsibility of the member if the service is provided by a non-participating provider. Status
changes are effective the date you specify or if no date is specified, on the first of the month following our receipt of
the enrollment form. Retroactive changes are limited to 30 days.
Enrolled Out-of-Area Dependents are responsible for obtaining prior authorization from the Plan prior to receiving certain
services from non-participating providers. For further information about prior authorization, including a list of these
covered services and how to obtain prior authorization, please refer to your Member Handbook.
When utilizing emergency services, Providence Health Plan must be notified within 48 hours or as soon as
reasonably possible.
To obtain coverage for your Out-of-Area Dependent, fill out the Out-of-Area Dependent Enrollment Form below and mail
it to Providence Health Plan, PO Box 4327, Portland, OR 97208-4327.
KEEP TOP HALF FOR YOUR RECORDS
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Providence Health Plan
MAIL TO:
FOR HEALTH
PROVIDENCE HEALTH PLAN
PLAN USE ONLY
P.O. Box 4327
Out-of-Area Dependent Enrollment Form
RP = DE
Portland, OR 97208-4327
MS = OA
Benefits for Out-of-Area Dependent Members are effective the date you specify below, or if no date is specified, on the
first of the month following our receipt of this enrollment form. Retroactive changes are limited to 30 days. Please
complete this form and return it to Providence Health Plan as soon as possible.
Employer Name ___________________________________________________ Group No. _______________________
Subscriber’s Name __________________________________________________________________________________
Subscriber’s Address ________________________________________________________________________________
City________________________________ State ________ Zip ____________ Member I.D No. __________________
1. Dependent’s Name _____________________________________________ Dependent’s Birthdate ______________
Dependent’s Address_____________________________________________________________________________
City ____________________________ State ________ Zip ____________ Member I.D. No. __________________
2. Dependent’s Name _____________________________________________ Dependent’s Birthdate ______________
Dependent’s Address_____________________________________________________________________________
City ____________________________ State ________ Zip ____________ Member I.D. No. __________________
Requested effective date if different from first of the month following our receipt of this form:
PLEASE PRINT, SIGN AND DATE IN SPACE BELOW
SUBSCRIBER’S SIGNATURE ______________________________________________ DATE ____________________
ENR-008B
OR/WA 0104 OOADEP
OOA Dep Enrollment
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