Forms and Materials for
Plan Administrators

Click on the categories below to download a wealth of materials. Please contact your Client Service Representative if you have a special request.

Want to promote health and wellness in your organization? Check out our Wellness Communication Toolkit.

Administrative Forms

Administering Existing Business

Accident Report
Agent of Record Appointment
Authorization to Use or Disclose PHI
Care Coordination Request	en Español
CHIPRA Notice	en Español
Dental Claim Form
Employee Address or Name Change	en Español
Group Authorization Agreement for Electronic Fund Transfers	en Español
Guide: PacificSource Model Notices
Participating Provider Directory Request
Prenatal Vitamin Home Delivery Order Form
Prescription Drug Claim
Provider Nomination Form–Advantage
Provider Nomination Form—BrightPath
Provider Nomination Form—First Health Network
Provider Nomination Form–IPN
Provider Nomination Form—PacificSource Network
Renewal Confirmation Form
Request Record Set Access

Enrolling New Members

Agent Checklist for New Group Enrollment
Authorization to Use or Disclose PHI
Care Coordination Request
Common Ownership Confirmation Form
Dual Choice Medical Plan Selection Form
Group Health Information Release
Participating Provider Directory Request
Prenatal Vitamin Home Delivery Order Form
Provider Nomination Form–Advantage
Provider Nomination Form—First Health Network
Provider Nomination Form–IPN
Provider Nomination Form—PacificSource Network
Request for Idaho Group Insurance (Master Application)
Request Record Set Access
Waiver of Coverage	en Español
Work Confirmation

Administering Continuation Coverage

COBRA General Notice Packet
COBRA Subsidy Extension Notice
Continuation Coverage Rights Under COBRA	en Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)	en Español
FAQ: COBRA Provisions of the ARRA

Medicare Part D Notices

Current Notices

Medicare Part D Creditability Matrix
Notice A (creditable): Employer Notice
Notice A (creditable): Sample Member Notice
Notice B (noncreditable): Employer Notice
Notice B (noncreditable): Sample Member Notice

Member Materials

General Education

Auditing Claims to Manage Costs: Controlling the Cost of Healthcare
Average Cost of Medical Care	en Español
Health Manager's Child Health Center
Online Provider Directory
Privacy Policy	en Español
Rising Healthcare Costs: Information and Tips	en Español
Seven Ways to Become an Informed Healthcare Consumer	en Español
Wellness Communication Toolkit

Plan Benefits

Benny MasterCard
Diabetes Benefits	en Español
Healthcare Benefits When Traveling	en Español
HealthCare FSA: The Smart Way to Pay
HRA Member Enrollment Kit
HSA Member Enrollment Kit
HSA Member Enrollment Kit (with HSA Bank Application)
International Travel	en Español
Life Events
Mail Order Pharmacy Options for Prescription Drugs	en Español
Mail Order Pharmacy Options Payroll Insert
Maternity Benefits	en Español
Tiered Prescription Drug Plan	en Español
Tiered Prescription Drug Plan (MacB)
Transplant Travel Benefit
Vison Benefits	en Español

Value-Added Programs and Services

Accordant Care Rare Disease Program	en Español
Expectations: A Free Prenatal Program	en Español
Expectations: Payroll Stuffer
First Health Network	en Español
Free & Clear Quit for Life Program (Tobacco Cessation)	en Español
Global Emergency Services Provided by Assist America
Global Emergency Services Tri-Fold Brochure	en Español
Health Management with PacificSource (for groups with 2 to 50 employees)	en Español
Health Management with PacificSource (for groups with 51 or more employees)	en Español
Healthy Returns Care Management Program	en Español
Hospital-Based Health Education Classes	en Español
InTouch and Health Manager Payroll Stuffer
InTouch: Online Access to Your Information
PacificSource Extras (BrightIdea and SmartHealth individual plans)
PacificSource Extras (for groups with 2 to 50 employees)	en Español
PacificSource Extras (for groups with 51 or more employees)	en Español
Prescription Discount Program (plans with prescription drug coverage)	en Español
Prescription Discount Program (plans with prescription drug coverage)	en Español
Prescription Discount Program (plans without prescription drug coverage)	en Español
Prescription Discount Program (plans without prescription drug coverage)	en Español
WebMD Lifestyle Improvement Programs

Sales Materials

About Our Products and Plan Designs

Consumer-Directed Health Plans
Dual Choice Healthcare Options
Group Dental Plans
Group Health Plan Designs
Health Reimbursement Arrangement (HRA)
Health Savings Account (HSA)
Integrated Health Savings Account Billing and Enrollment
Life and Disability Quote Sheet
Life and Disablilty Insurance
Managed Pharmacy Benefit Designs
Manley Services Healthcare FSA
PacificSource Optional Benefits

About Our Programs and Services

Coordination of Benefits
Cost Containment Through Care Management
First Health Network
Global Emergency Services from Assist America
Health Management with PacificSource
Health Manager and Biometric Screenings
LifeTrac Transplant Network
Online Employee Wellness Communication Toolkit
PacificSource Network: Hospitals
PacificSource Network: Urgent Care
Prescription Discount Program
Spanish Language Services & Materials
Value-Added Programs & Services
Wellness Brown Bag Seminars

About PacificSource

About Us
Case Study: Oregon Research Institute
Community Health Excellence Program
Community Service
Financial Performance
Idaho Client Testimonials
Operational Performance
Our Customers: Guistina Land and Timber Co.
Our Customers: The Pape' Group
Our History
Straight Talk About Healthcare Costs
The PacificSource Bottom Line
We're In It for the People

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Last updated 4/9/2009

Forms and Materials for Plan Administrators