Oregon Continuation Election Form - Providence Health Plans - healthplans providence 2025

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  1. Click ‘Get Form’ to open the Oregon Continuation Election Form in the editor.
  2. Begin by filling out Section 1 with your personal information. Enter your last name, first name, middle initial, address, date of birth, gender, daytime phone number, member ID number, group number, and marital status.
  3. In Section 2, provide your Social Security number and select your qualifying event for continuation coverage. Be sure to include relevant dates for employment termination or other events as applicable.
  4. List any dependent family members who will continue coverage in Section 3. Fill in their last names, first names, middle initials, dates of birth, genders, and relationships to you.
  5. Finally, review the accuracy of your information and sign in the designated area in Section 4. Ensure you date the form before submission.

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