Oregon Medical Insurance > PacifiCare > Download Application

PacifiCare of Oregon HMO Enrollment Form | PacifiCare SDA Enrollment Form

Tips for completing your application:

1. 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.
   
   
2. 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 spelling.
   • 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.
   
   
3. 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 PacifiCare Health Plans of Oregon or PacifiCare Life Assurance Company.
   
   
4. You Must Include Your First Months Payment: Make sure to include your first months payment with the application. This can be done by check or a credit card (with a credit card, you can fax in your application).
   
   • Monthly Bank Draft:  Please complete Authorization Form carefully and attach a voided check. (Deposit slip does not work!)
     
   • Direct Bill:  Simply check the Direct bill , and you are done.
   • Credit/Debit Card: Download and complete Authorization Form and submit with application. (Only for 1st month's premium)
     
     
5. Final check list before mailing or faxing to 541.284.2994:
   • All sections completed?
   • Copy of Insurance Card or Certificate of Creditable Coverage
   • Signed and Dated
   • Voided check if selecting the automated monthly withdrawal
     
     
6. Send all Enrollment Materials to:
   CDA Insurance LLC
   PO Box 26540
   Eugene, OR 97402
   
   FAX Number: 541.284.2994