Providence Health Plan Out-of-Area Dependent Enrollment Form Completed Form Examples and Samples
View filled-out examples and samples of the Providence Health Plan Out-of-Area Dependent Enrollment Form. Learn how to correctly complete the form for dependents, such as college students, who live outside the plan's service area.
Providence Health Plan Out-of-Area Dependent Enrollment Form Example
How this form was filled:
This example shows how an employee can enroll a dependent who is a full-time college student living outside the health plan's service area. The form correctly details the subscriber's information, the dependent's personal and school information, and is properly signed for the upcoming plan year.
Information used to fill out the document:
- Subscriber Name: Jane M. Smith
- Subscriber ID: PH987654321
- Employer Name: Tech Solutions Inc.
- Group Number: TS54321
- Dependent Name: Michael T. Smith
- Dependent Date of Birth: 08/15/2006
- Dependent Relationship: Son
- Dependent Gender: Male
- Dependent Address: 123 University Ave, Boulder, CO 80309
- Reason for Request: New Enrollment
- School Name: Out-of-State University
- School City, State, ZIP: Boulder, CO 80309
- Student Status: Full-Time
- Signature of Employee: Jane M. Smith
- Date of Signature: 11/15/2025
What this filled form sample shows:
- Accurate completion of Subscriber and Employer information.
- Detailed Dependent information, including their out-of-area address.
- Clear indication of Student Status with school name and location.
- Properly signed and dated by the employee to authorize the enrollment.
Form specifications and details:
| Use Case: | Enrolling an out-of-area dependent who is a full-time college student. |
| Form Name: | Providence Health Plan Out-of-Area Dependent Enrollment Form |
| Plan Year: | 2026 |
Created: February 12, 2026 07:28 PM
