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

2017 Oregon Small Group Brochure
2017 Oregon Small Group Brochure - Dental Only
2017 Voluntary Dental Brochure
2018 Oregon Small Group Brochure
Consumer-Directed Health Plans
Right Fit Healthcare Options

Quote Small Groups

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

Enroll New Small Group

2017 Enrollment Application (Group Dental)en Español
2017 Enrollment Application (Group Health-Dental)en Español
2017 Group Master Application (Dental)
2017 Group Master Application (Medical)
2017 SHOP Participation Request (OHIM document)
2018 Group Enrollment Application (Dental Only)
2018 Group Enrollment Application (Medical and Dental)
2018 Group Master Application (Dental Only)
2018 Group Master Application (Medical and Dental)
Agent Checklist for New Group Enrollment
Common Ownership Confirmation Form
Group Authorization Agreement for Recurring Electronic Fund Transfers
Split Carrier Waiver of Coverage
Waiver of Coverageen Español

Small Group Administrative Forms

2018 Renewal Confirmation Form
Common Ownership Confirmation Form
Oregon Health Insurance Marketplace Renewal for Employers
Right Fit Selection Form Template
Short Form Add Dental

Large Group Forms and Fliers

Provide Plan Information

2017 Oregon Large Group Brochure
2017 Oregon Large Group Dental Brochure
2017 Self-funded Dental Plans
2017 Voluntary Dental Brochure
2018 Oregon Large Group Brochure
Consumer-Directed Health Plans
Incentive Care Package
Right Fit Healthcare Options

Quote Large Groups

Oregon Group Identification Form
Quote Request - Groups with 51+ Employees

Enroll New Large Group

2017 Enrollment Application (Group Dental)
2017 Enrollment Application (Group Health-Dental)
2017 Group Master Application (Dental)
2017 Group Master Application (Medical)
2018 Group Enrollment Application (Dental Only)
2018 Group Enrollment Application (Medical and Dental)
2018 Group Master Application (Dental Only)
2018 Group Master Application (Medical and Dental)
Agent Checklist for New Group Enrollment
Common Ownership Confirmation Form
Group Authorization Agreement for Recurring Electronic Fund Transfers
Split Carrier Waiver of Coverage
Waiver of Coverage

Large Group Administrative Forms

2018 Renewal Confirmation Form
Common Ownership Confirmation Form
Right Fit Selection Form Template
Short Form Add Dental

HRAs HSAs and Life

InTouch for Agents

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Last updated 10/3/2014

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