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Get OR Providence Health Plan PHP-112D 2012-2024

Or fewer employees, or Employer Groups not subject to COBRA If you wish to apply for Oregon continuation coverage, you must complete all sections of this form and return it to your employer within 10 days of the qualifying event or 10 days of receiving your notice of continuation coverage, whichever is later. SECTION 1 LAST NAME QUALIFYING INDIVIDUAL INFORMATION FIRST NAME M.I. ADDRESS (STREET, CITY, STATE, ZIP CODE) DATE OF BIRTH GENDER DAYTIME PHONE MEMBER ID NO. GROUP NO. MARITAL S.

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