Oregon Continuation Election Form - Providence Health Plans - healthplans providence 2026

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, including 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 the qualifying event that applies to you. Be sure to include relevant dates for employment termination or other events as necessary.
4. If applicable, indicate whether anyone applying for continuation is covered by another group insurance and provide the required details.
5. List all dependent family members continuing coverage in Section 3 by entering their last names, first names, middle initials, dates of birth, genders, and relationships.
6. Finally, review the accuracy of your information and sign the form in Section 4. Ensure you date your signature before submitting it back to your employer.

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