This page includes comprehensive information that is not specific to any one plan. If you are insured by PacificSource, keep in mind that this information may not all be applicable to your specific benefits. If you have questions about your plan's coverage, please check your benefit materials or contact our Customer Service Department.

Forms & Materials

You're welcome to download the following forms and educational materials.

Forms

Accident Report Form

Address/Name Change Form                                          en Español

Authorization to Use/Disclose PHI

Care Coordination Request Form                                    en Español

Dental Services Claim Form

Hospital-Based Health Education Classes                       en Español

Prescription Drug Claim Form

Provider Network Nomination Form - PacificSource

Provider Network Nomination Form - First Health Network

General Educational Materials

Auditing Claims to Manage Costs

Average Cost of Care                                                     

Health Management With PacificSource

InTouch for Members

Our Privacy Policy                                                          en Español

Provider Directory Instructions

Rising Healthcare Costs: Information and Tips                   en Español

Third Party Recovery in Oregon                                        en Español

Understanding Your Diabetes Benefits                              en Español

Using Your Tiered Prescription Drug Plan                         

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