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Oregon Continuation Election Form - Providence Health Plans - healthplans providence 2026
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- Click ‘Get Form’ to open the Oregon Continuation Election Form in the editor.
- 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.
- 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.
- If applicable, indicate whether anyone applying for continuation is covered by another group insurance and provide the required details.
- 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.
- 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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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2012 | 4.9 Satisfied (48 Votes) |
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