Forms and Materials for
Employers

Click on the categories below to download 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

Group Change Guidelines

Enrolling New Members

Advantage Renewal Confirmation
Dual Choice Medical Plan Selection Form
Group Dental Enrollment Application
Group Health-Dental Enrollment Application	en Español
Group Profile Form
HRA Account Setup Worksheet
HSA Integrated Billing Employer Packet
HSA Member Enrollment Kit (with HSA Bank Application)
Life and Disability - Agent Forms
Life and Disability - Employer Application for Group Life
Life and Disability - Member Enrollment
Waiver of Coverage	en Español

Administering Existing Coverage

Accident Report
Affidavit of Domestic Partnership
Agent of Record Appointment
Authorization to Use or Disclose PHI
Care Coordination Request	en Español
CHIPRA Notice	en Español
Dental Claim Form
Disabled Dependent Certification
Employee Address or Name Change	en Español
Group Authorization Agreement for Recurring Electronic Fund Transfers
Group Change Guidelines
Guide: PacificSource Model Notices
Plan Administrator Manual
Prenatal Vitamin Home Delivery Order Form
Prescription Drug Claim Form
Provider Nomination Form–Advantage
Provider Nomination Form–First Health Network
Provider Nomination Form–IPN
Provider Nomination Form–PacificSource Network
Renewal Confirmation Form
Request Record Set Access
Termination of Dependent Coverage

Administering Continuation Coverage

Additional Election Notice Packet
CMS ARRA Appeal Form
COBRA Extended Election Period Notice Packet
COBRA General Notice Packet
COBRA New Election Period Notice Packet
COBRA Supplemental Notice Packet
COBRA_Subsidy_Extension_Notice
Continuation Coverage Rights Under COBRA	en Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)	en Español
Continuation Election Form (State)
DOL ARRA Appeal Form
FAQ: COBRA Provisions of the ARRA
FAQ: Oregon State Continuation
Oregon State Continuation Packet

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
Average Cost of Medical Care	en Español
Health Manager's Child Health Center
Health Resources for You and Your Family	en Español
How to Submit a Claim
International Travel	en Español
Making Sense of Third Party Recovery	en Español
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
Dental: How to Maximize Your Dental Benefits	en Español
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)
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)
Tiered Value Prescription Drug Plan	en Español
Transplant Travel Benefit
Vision Benefits	en Español

Value-Added Programs and Services

Accordant Care Rare Disease Program	en Español
Chronic Disease Self-Management Program
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	en Español
Global Emergency Services Tri-fold Brochure
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
Hospital-Based Health Education Classes	en Español
InTouch and Health Manager Payroll Insert
InTouch: Online Access to Your Information
Member Guide	en Español
PacificSource Extras (for groups with 2 to 50 employees)	en Español
PacificSource Extras (for groups with 51 or more employees)	en Español
PacificSource Extras: Payroll Stuffer
Prescription Discount Program (plans with prescription drug coverage)	en Español
Prescription Discount Program (plans without prescription drug coverage)	en Español
WebMD Lifestyle Improvement Programs
Weight Watchers Pilot Program
Weight Watchers Pilot Program: Payroll Stuffer

Sales Materials

About Our Products and Plan Designs

Chiropractic and Alternative Care Benefits
Consumer-Directed Health Plans
Dental Advantage Plans
Dual Choice Healthcare Options - Large Group
Dual Choice Healthcare Options - Small Group
Group Dental Plans
Group Health Plan Designs
Health Reimbursement Arrangement (HRA)
Health Savings Account (HSA)
Healthcare Savings Vehicles at a Glance
HSA FAQ
Integrated Health Savings Account Billing and Enrollment
Life and Disability Quote Sheet
Life and Disablilty Insurance
Local Bank for Your HSA
Managed Pharmacy Benefit Designs
Manley Services Healthcare FSA
PacificSource Network: Hospitals
PacificSource Network: Urgent Care
PacificSource Optional Benefits
Short Term Medical Coverage

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
InTouch for Administrators
InTouch for Agents
LifeTrac Transplant Network
Online Employee Wellness Communication Toolkit
Online Enrollment at PacificSource.com
Prescription Discount Program
Spanish Language Services and Materials
Value-Added Programs and Services
Wellness Brown Bag Seminars

About PacificSource

About Us
Community Health Excellence Program
Community Service
Financial Performance
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

Tutorials

InTouch for Administrators

InTouch Tutorial: Add a Dependent
InTouch Tutorial: Census Report
InTouch Tutorial: Contracts
InTouch Tutorial: Member Benefits
InTouch Tutorial: Member Search
InTouch Tutorial: New Enrollment
InTouch Tutorial: Order ID Cards
InTouch Tutorial: Pop-up Window Troubleshooting Tips
InTouch Tutorial: Pre-enrollment Information
InTouch Tutorial: Register Your User ID
InTouch Tutorial: Reinstate a Dependent
InTouch Tutorial: Reinstate a Subscriber
InTouch Tutorial: Terminate a Dependent
InTouch Tutorial: Terminate a Subscriber
InTouch Tutorial: Track Requests
InTouch Tutorial: Update a Dependent
InTouch Tutorial: Update Addresses

InTouch Login

Access your PacificSource account information 24/7.

Help your employees get engaged!

Our Workplace Wellness Toolkit includes posters, payroll stuffers, and newsletter articles you can use to promote healthy behaviors in your workplace.

Last updated 7/26/2010

Forms and Materials for Employers