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PacificSource Health Plans Information for Employers

This page provides information and documents that are designed specifically for businesses covered by the Bend Chamber Association Plans.

Employer Forms and Fliers (PDFs)

2020 Sales Brochure 

2020 Enrollment Application and Waiver of Coverage

2020 Renewal Confirmation

2020 Notice of Change

COBRA Administration Application (through PacificSource Administrators)

Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)

Termination of Dependent Coverage

If you do not elect COBRA administration through PacificSource Administrators, please use the forms below:

USAable Life:

Medicare Part D Creditability Matrix (2020)

Value-added Programs and Services

Winning at Wellness How-to Guide (4.5 Mb)

More forms and materials for employers >

Member Fliers (PDFs)

InTouch: Access Your Plan Info from Your Computer, Tablet, or Phone

Provider Directory - Online

Quit For Life (tobacco cessation program)  en Español

24-Hour NurseLine  en Español

CaféWell: Personalized Healthy Life Guidance  

Health Education Classes  en Español

More forms and materials for members >

Your Wellness Commitment

This section contains resources for groups who are new to PacificSource and have committed to the two wellness requirements.

The Commitment Requirements:

  1. Participate in an approved Worksite Wellness workshop, facilitated by Johnson Benefit Planning and PacificSource Health Plans .
  2. Promote the Winning at Wellness monthly toolkit. (Sign up to receive the Winning at Wellness monthly toolkit via email at Commit to hanging posters and disseminating the newsletter article to employees each month.)

Read more about your wellness commitment and deadline:

Wellness Certificate – 2019 Plans (PDF)

Wellness Certificate – 2019 4th Quarter Plans (PDF)

Wellness Certificate – 2020 Plans (PDF) 

Wellness Commitment Materials (PDFs)

Winning at Wellness How-to Guide (4.5 Mb)

Wellness Toolkit > (Promote health and wellness with our posters, newsletter articles, and more.)

Flu Shot and Vaccine Information > (See the Wellness Toolkit for related flu materials.)

Wellness commitment questions or to sign up for the monthly Winning at Wellness monthly toolkit

Tiana Wilkinson, Wellness Consultant
Toll-free: (866) 540-1191, ext. 2519
Email: or

Do your members need assistance in logging into InTouch or CaféWell? 

InTouch Login Assistance 
Call PacificSource Customer Service at (888) 977-9299, or email

CaféWell Assistance 
Call (800) 390-5019, or email You can also contact the CaféWell support team by clicking “Help” at the bottom of any CaféWell page, and submitting your question via email.


Please feel free to contact us if you have questions, 8:00 a.m. to 5:00 p.m. (Pacific), Monday through Friday

Group Benefit Information

Customer Service
Toll-free: (888) 977-9299, TTY: (800) 735-2900

Enrollment and Billing

Membership Services  
Toll-free: (866) 999-5583, TTY: (800) 735-2900
Fax: (541) 225-3642

InTouch for Employers

Access your PacificSource account information 24/7.

Last updated 5/6/2020