Forms and Materials for Agents

Click on the categories below to download materials. Please feel free to contact your PacificSource regional office if you have a special request.

Brochures and Sales Materials

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 (updated January 17, 2012)
Health Reimbursement Arrangement (HRA)
Healthcare Savings Vehicles at a Glance
HSA FAQ
HSA: Health Savings Account
HSA: Integrated Health Savings Account Billing and Enrollment
Incentive Care Package - Large Group
Life and Disability Insurance
Life and Disability Quote Sheet
Local Bank for Your HSA
Managed Pharmacy Benefit Designs
Manley Services Healthcare FSA
PacificSource Network: Hospitals
PacificSource Network: Urgent Care
PacificSource Optional Benefits
Right Fit Healthcare Options - Small Group

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 Agents
InTouch for Employers
LifeTrac Transplant Network
Online Employee Wellness Communication Toolkit
Online Enrollment at PacificSource.com
Online Quoting through InTouch for Agents
Prescription Discount Program
Spanish Language Services and Materials
Value-Added Programs and Services
Weight Management Resources for Members
Weight Management: Payroll Stuffer
Wellness Brown Bag Seminars
Workplace Wellness Coordinators

About Us
Community Health Excellence Program
Community Service
Financial Performance
Operational Performance
Our Customers: Guistina Land and Timber Co.
Our History
Straight Talk About Healthcare Costs
The PacificSource Bottom Line
We're In It For The People

Agent Checklist for New Group Enrollment
Coordination of Benefits Form
Group Dental Enrollment Application
Group Health-Dental Enrollment Application	en Español
Group Profile Form
HRA Account Setup Worksheet
HSA Integrated Billing Employer Packet
Life and Disability - Agent Forms
Life and Disability - Employer Application for Group Life
Life and Disability - Member Enrollment
Request for Oregon Group Insurance (Master Application 100+)
Request for Oregon Group Insurance (Master Application 2-99)
Right Fit Addendum
Short Form Add Dental
Waiver of Coverage	en Español

Agent Checklist for New Group Enrollment
Dual Choice Medical Plan Selection Form
Group Dental Enrollment Application
Group Health-Dental Enrollment Application
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
Request for Oregon Group Insurance (Master Application 100+)
Request for Oregon Group Insurance (Master Application 2-99)
Right Fit Addendum
Short Form Add Dental
Waiver of Coverage

Common Ownership Confirmation Form
Group Profile Form FAQ
Oregon Standardized Group Profile Form
Owners Work Confirmation Form
Proposal Request - Groups with 2-50 Employees
Proposal Request - Groups with 51+ Employees

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
Designation of Authorized Representative
Direct Deposit for Commission Checks
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

Continuation Coverage Rights Under COBRA	en Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)	en Español
Continuation Election Form (State)
Continuation: Additional Election Notice Packet
Dual Choice Medical Plan Selection Form
FAQ: Oregon State Continuation
Oregon State Continuation Packet

Affidavit of Domestic Partnership
Agent iStore Quick Reference Guide
Elect Application Tips
Elect Application Tips for Agents
Elect Brochure (January 1, 2012)
Elect Dental Brochure (January 1, 2012)
Elect Dental Trifold (January 1, 2012)
Elect Individual Policy Change Form
Elect Policy Application
Elect Policy Premium Rates (January 1, 2011)
Elect Policy Premium Rates (January 1, 2012)
Elect Trifold Brochure (January 1, 2012)
Elect_Dental_only_app_0111
Electronic Funds Transfer (EFT) Authorization
Individual Sales FAQ: Answers to Your Questions
Top Reasons to Sell Elect Individual and Family Plans

Auditing Claims to Manage Costs
Average Cost of Medical Care	en Español
Doctor Office Visit Guide	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
Preventive Care: Understanding Your Benefits - Oregon
Privacy Policy	en Español
Rising Healthcare Costs: Information and Tips	en Español
Seven Ways to Become an Informed Healthcare Consumer	en Español

Auditing Claims to Manage Costs
Average Cost of Medical Care
Benny MasterCard
Dental: How to Maximize Your Dental Benefits	en Español
Diabetes Benefits	en Español
Health Resources for You and Your Family
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
Life Events
Mail Order Pharmacy Options for Prescription Drugs	en Español
Mail Order Pharmacy Options Payroll Insert
Making Sense of Third Party Recovery
Maternity Benefits	en Español
Online Provider Directory
Privacy Policy
Rising Healthcare Costs: Information and Tips
Seven Ways to Become an Informed Healthcare Consumer
Transplant Travel Benefit
Vision Benefits	en Español

Accordant Care Rare Disease Program	en Español
Chronic Disease Self-Management Program
First Health Network	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
Jenny Craig
Jenny Craig: Payroll Stuffer
Member Guide	en Español
Member Guide (for members with dental-only plans)
Prenatal Program
Prenatal Program payroll stuffer
Prescription Discount Program (plans with prescription drug coverage)	en Español
Prescription Discount Program (plans without prescription drug coverage)	en Español
Quit for Life Program (Tobacco Cessation)
WebMD Lifestyle Improvement Programs
Weight Watchers Pilot Program
Weight Watchers Program 2012
Weight Watchers Program: Payroll Stuffer

Medicare Part D Creditability Matrix 2011
Notice A (creditable): Employer Notice
Notice A (creditable): Sample Member Notice
Notice B (noncreditable): Employer Notice
Notice B (noncreditable): Sample Member Notice
Notice C (noncreditable, change): Employer Notice
Notice C (noncreditable, change): Sample Member Notice