PacificSource Forms
for Idaho
You're welcome to download the following administrative forms, or contact your PacificSource Client Service Representative to request hard copies. These forms can be completed online before printing; see our Q&A for more information.
Enrolling New Members:
Small Group Enrollment Application
Large Group Enrollment Application
Group Health Information Release
Waiver of Coverage
Additional form for Dual Choice packages:
Administering
Existing Coverage:
Authorization to Use/Disclose PHI
Provider Nomination Form - PacificSource Networks
Provider Nomination Form - First Health Network
Unless otherwise stated, all text and images © 2006 PacificSource. All rights reserved.