PacificSource Forms for Idaho

You're welcome to download the following administrative forms, or contact your regional office to request hard copies. These forms can be completed online before printing; see our Q&A for more information.

Requesting Quotes:
Proposal Request

Streamlining Your Quote Process
Small Group Enrollment Application
Large Group Enrollment Application
Common Ownership Confirmation Form

Enrolling New Business:
Agent Checklist for New Groups
Request for Group Insurance
Group Health Information Release
Waiver of Coverage

Additional form for Dual Choice packages:

Dual Choice Medical Plan Selection Form

Administering Existing Business:

Address/Name Change

Agent Commission Direct Deposit Authorization

Agent of Record Appointment

Authorization to Use/Disclose PHI

Care Coordination Request

Dental Services Claim

Prescription Drug Claim

Provider Nomination Form - PacificSource Networks

Provider Nomination Form - First Health Network

Renewal Confirmation

*Spanish version available on our Spanish Materials page

Unless otherwise stated, all text and images © 2006 PacificSource. All rights reserved.