Forms and Fliers for Oregon Agents

The documents on this page were designed to help you enroll your clients with PacificSource Health Plans. Please contact us if you have a special request.

You'll find more Oregon forms and fliers on our Member and Employer Forms and Fliers pages.

About PacificSource

Programs and Services

Online Access

Individual Forms and Fliers

Small Group Forms and Fliers

Provide Plan Information

2018 Oregon Small Group Brochure
2018 Oregon Small Group Brochure - Dental Only
2019 Oregon Small Group Brochure
2019 Oregon Small Group Brochure - Dental Only
2019 Oregon Small Group Medical Plan Comparison
2019 Sample Limitations and Exclusions (Medical)
2019 Voluntary Dental Brochure
Forms and Materials
HSA: Your HSA Works for You - The Health Savings Account
Idaho Forms and Materials
Montana Forms and Materials
Oregon Forms and Materials
Right Fit Healthcare Options

Quote Small Groups

2017 SHOP Participation Request (OHIM document)
Group Identification Form
Quote Request

Enroll New Small Group

2017 SHOP Participation Request (OHIM document)
2018 Group Enrollment Application and Waiver (Dental Only)
2018 Group Enrollment Application and Waiver (Medical/Dental)en Español
2018 Group Master Application (Dental Only)
2018 Group Master Application (Medical/Dental)
2019 Group Enrollment Application and Waiver (Medical/Dental)en Español
2019 Group Master Application (Medical/Dental)
Common Ownership Form
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
RightFit Plan and PCP Selection Formen Español
Sold Groups Enrollment Checklists
Split Carrier Waiver of Coverage

Small Group Administrative Forms

Group Renewal Confirmation
Oregon Health Insurance Marketplace Renewal for Employers

Large Group Forms and Fliers

Provide Plan Information

2018 Oregon Large Group Brochure
2018 Oregon Large Group Dental-only Brochure
2018 Voluntary Dental Brochure
2019 Oregon Large Group Brochure
2019 Oregon Large Group Brochure - Dental Only
2019 Oregon Self-Funded Dental Brochure
2019 Sample Limitations and Exclusions (Medical)
2019 Voluntary Dental Brochure
Forms and Materials
HSA: Your HSA Works for You - The Health Savings Account
Idaho Forms and Materials
Montana Forms and Materials
Oregon Forms and Materials
Right Fit Healthcare Options
Self-Funded Administrative Solutions

Quote Large Groups

Group Identification Form
Quote Request - Groups with 51+ Employees

Enroll New Large Group

2018 Group Enrollment Application and Waiver (Dental Only)
2018 Group Enrollment Application and Waiver (Medical/Dental)
2018 Group Master Application (Dental Only)
2018 Group Master Application (Medical/Dental)
2019 Group Enrollment Application and Waiver (Medical/Dental)
2019 Group Master Application (Medical/Dental)
2019 Student Health Master Application (Medical/Dental)
Common Ownership Form
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
RightFit Plan and PCP Selection Form
Sold Groups Enrollment Checklists
Split Carrier Waiver of Coverage

Large Group Administrative Forms

Group Renewal Confirmation

HRAs and HSAs

InTouch for Agents

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Last updated 10/3/2014

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