Please read everything carefully and answer all questions honestly. This document becomes part of your health insurance contract. Please make
sure you have downloaded and completed the correct application.
Please complete all sections to the best of your ability. Please pay special
attention to the health history Section. By including the specific
details to questions you answered "yes" to - the processing of
your application will be expedited. Be sure to include:
The specific name and date of the diagnosis or condition and correct
The treatment(s) that were done, including the last time you visited
the doctor for this condition and medications that were prescribed and
medications that are currently being taken.
Final result refers to the status of the condition. If it has been
treated and your doctor has not requested any follow-ups, please state
so. If you are still seeing the doctor, please state so.
Complete name, address and phone number of the doctor.
Provide Certificate of Creditable Coverage (if available)
Please refer to Credit
for Prior Coverage Eligibility for more information. Please
note, if you do not have your Certificate of Creditable Coverage at the
time of application, please submit your application anyway. Credit for pre-existing
condition waiting periods will be credited upon receipt of your Certificate
of Creditable Coverage by Providence Health Plans of Oregon.
Do not include any payments with this application: The payment
options are monthly bank draft or direct bill. You will be contacted on
approval for payment and the payment options that are available to you
Final check list before mailing:
All sections completed?
Copy of Insurance Card or Certificate of Creditable Coverage
Signed and Dated
Send all Enrollment Materials to:
CDA Insurance LLC
PO Box 26540
Eugene, OR 97402