PacificSource Forms
for Oregon
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:
For all clients:
Group Health/Dental Enrollment*
Group Dental Enrollment (for dental-only clients)
Additional forms for clients with FlexPerks HRAs:
Additional forms for clients with integrated HSA Bank billing/enrollment:
HSA Employer Forms Packet - all required employer forms in a single file
HSA Member Enrollment Packet - all employee information and forms in a single file
Additional form for Dual Choice packages:
Dual Choice Medical Plan Selection Form
Additional forms for life and disability coverage:
Request for Group Life/Disability Insurance - agent and employer forms
Group Life/Disability Enrollment Packet - member forms
Administering
Existing Coverage:
Authorization to Use/Disclose PHI
Continuation Election – Dental Only
Continuation Election – Federal*
Continuation Election – State*
Continuation Initial Notice – Federal*
Disabled Dependent Certification
Provider Nomination Form - PacificSource Networks
Provider Nomination Form - First Health Network
*Spanish version available on our Spanish Materials page
Unless otherwise stated, all text and images © 2006 PacificSource. All rights reserved.