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Idaho-Gateway-GraphicForms and Materials for Agents

Click on the categories below to download materials. Please feel free to contact our Boise Regional Office at (208) 342-3709 or (888) 492-2875 if you have a special request. 

Brochures and Sales Materials

About PacificSource

About Us
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

About Our Products and Plan Designs

Consumer-Directed Health 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)
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

New Group Enrollment Forms

Administrative Forms

Administering Existing Business

Accident Report
Agent of Record Appointment
Authorization to Use or Disclose PHI
Care Coordination Requesten Español
CHIPRA Noticeen Español
Dental Claim Form
Direct Deposit for Commission Checks
Employee Address or Name Changeen Español
Group Authorization Agreement for Electronic Fund Transfersen Español
Group Change Guidelines
Guide: PacificSource Model Notices
How to Submit a Claim
Plan Administrator Manual
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 Business

Advantage Renewal Confirmation
Agent Checklist for New Group Enrollment
Common Ownership Confirmation Form
Dual Choice Medical Plan Selection Form
Group Health Information Release
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
Request for Idaho Group Insurance (Master Application)
Waiver of Coverage
Work Confirmation

Requesting Quotes

Enrollment Application (Large Group 100+)
Enrollment Application (Large Group)
Enrollment Application (Small Group)
Group Health Information Release
Idaho Proposal Request
Idaho Proposal Request (Excel format)
Streamlining Your Quote Process
Universal Application

Administering Continuation Coverage

COBRA General Notice Packet
COBRA_Extended_Election_Period_Notice_Packet
COBRA_New_Election_Period_Notice_Packet
COBRA_Supplemental_Notice_Packet
Continuation Coverage Rights Under COBRAen Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)en Español
FAQ: COBRA Provisions of the ARRA

Individual Policy Materials

Member Materials

General Education

Auditing Claims to Manage Costs: Controlling the Cost of Healthcare
Average Cost of Medical Careen Español
Health Manager's Child Health Center
Online Provider Directory
Privacy Policyen Español
Rising Healthcare Costs: Information and Tipsen Español
Seven Ways to Become an Informed Healthcare Consumeren Español

Plan Benefits

Benny MasterCard
Diabetes Benefitsen Español
Healthcare Benefits When Travelingen 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 Travelen Español
Life Events
Mail Order Pharmacy Options for Prescription Drugsen Español
Mail Order Pharmacy Options Payroll Insert
Maternity Benefitsen Español
Tiered Prescription Drug Plan
Tiered Prescription Drug Plan (MacB)en Español
Transplant Travel Benefit
Vison Benefitsen Español

Value-Added Programs and Services

Accordant Care Rare Disease Programen Español
Chronic Disease Self-Management Program
Expectations: A Free Prenatal Programen Español
Expectations: Payroll Stuffer
First Health Networken Español
Free & Clear Quit for Life Program (Tobacco Cessation)en Español
Global Emergency Services Provided by Assist America
Global Emergency Services Tri-Fold Brochureen 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
Hospital-Based Health Education Classesen Español
InTouch and Health Manager Payroll Stuffer
InTouch: Online Access to Your Information
Member Guideen Español
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
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
InTouch Account Help

InTouch Login

Access your PacificSource account information 24/7.

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Last updated 4/10/2009
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