Forms and Materials for
Employers

Click on the categories below to download a wealth of materials. Please contact your Client Service Representative if you have a special request.

Want to promote health and wellness in your organization? Check out our Wellness Communication Toolkit.

Administrative Forms

Enrolling New Members

Agent Checklist for New Group Enrollment
Authorization to Use or Disclose PHI	en Español
Care Coordination Request	en Español
Claim Form - Dental
Common Ownership Confirmation Form
Coordination of Benefits Form
Designation of Authorized Representative
Dual Choice Medical Plan Selection Form
Group Dental Enrollment Application
Group Health Information Release
How to Submit a Claim
HSA Member Enrollment Kit (with HSA Bank Application)
Idaho Individual Application for BrightIdea and SmartHealth individual plans
Life and AD&D - Employer Application for Group Life
Life and AD&D - Member Enrollment
Prenatal Vitamin Home Delivery Order Form
Provider Nomination Form–Advantage
Provider Nomination Form—First Health Network
Provider Nomination Form–IPN
Provider Nomination Form—PacificSource Network
Request Record Set Access
Restrict Record Set Access
Waiver of Coverage	en Español
Work Confirmation

Administering Existing Business

Accident Report
Affidavit of Domestic Partnership
Agent of Record Appointment
Authorization to Use or Disclose PHI
Care Coordination Request
CHIP Notice	en Español
Claim Form - Dental
Coordination of Benefits Form
Designation of Authorized Representative
Employee Address or Name Change	en Español
Group Authorization Agreement for Electronic Fund Transfers
Group Change Guidelines
Guide: PacificSource Model Notices
How to Submit a Claim
Idaho Individual Application for BrightIdea and SmartHealth individual plans
Off Renewal Change Form
Prenatal Vitamin Home Delivery Order Form
Prescription Drug Claim
Provider Nomination Form–Advantage
Provider Nomination Form—BrightPath
Provider Nomination Form—First Health Network
Provider Nomination Form–IPN
Provider Nomination Form—PacificSource Network
Renewal Confirmation Form
Request Record Set Access
Restrict Record Set Access

Administering Continuation Coverage

Affidavit of Domestic Partnership
Continuation Coverage Rights Under COBRA	en Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)	en Español
Guide: PacificSource Model Notices

Medicare Part D Notices

CHIP Notice
Guide: PacificSource Model Notices

Current Notices

Medicare Part D Creditability Matrix 2012
Notice A (creditable) Sample Member Notice
Notice A (creditable): Employer Notice
Notice B (noncreditable) Sample Member Notice
Notice B (noncreditable): Employer Notice
Notice C (noncreditable, change) Sample Member Notice
Notice C (noncreditable, change): Employer Notice

Member Materials

General Education

Auditing Claims to Manage Costs: Controlling the Cost of Healthcare
Average Cost of Medical Care	en Español
Doctor Office Visit Guide	en Español
Health Manager's Child Health Center
Online Provider Directory
Preventive Care: Understanding Your Benefits - Idaho
Privacy Policy	en Español
Provider Nomination Form - Bright Path
Rising Healthcare Costs: Information and Tips	en Español
Seven Ways to Become an Informed Healthcare Consumer	en Español
Wellness Communication Toolkit

Plan Benefits

Benny MasterCard
Diabetes Benefits	en Español
Healthcare Benefits When Traveling	en Español
HealthCare FSA: The Smart Way to Pay
HRA Member Enrollment Kit
HSA Member Enrollment Kit
HSA Member Enrollment Kit (with HSA Bank Application)
International Travel	en Español
Life Events
Mail Order Pharmacy Options for Prescription Drugs	en Español
Mail Order Pharmacy Options Payroll Insert
Maternity Benefits	en Español
Tiered Prescription Drug Plan
Tiered Prescription Drug Plan (MacB)	en Español
Transplant Travel Benefit
Vison Benefits	en Español

Value-Added Programs and Services

Accordant Care Rare Disease Program	en Español
Chronic Disease Self-Management Program
First Health Network	en Español
Global Emergency Services Provided by Assist America
Global Emergency Services Tri-Fold Brochure	en Español
GlobalFit Discounted Gym Membership Program
Health Management with PacificSource (for groups with 2 to 50 employees)	en Español
Health Management with PacificSource (for groups with 51 or more employees)	en Español
Hospital-Based Health Education Classes	en Español
InTouch and Health Manager Payroll Stuffer
InTouch: Online Access to Your Information
Jenny Craig
Jenny Craig: Payroll Stuffer
Juvenile Diabetes Program
Member Guide	en Español
Member Guide (for members with dental-only plans)
My Health Assistant
Prenatal Program	en Español
Prenatal Program payroll stuffer
Prescription Discount Program (plans with prescription drug coverage)	en Español
Prescription Discount Program (plans without prescription drug coverage)	en Español
Quit for Life Program (Tobacco Cessation)	en Español
Value Added Programs and Services (large group)
Value Added Programs and Services (small group)
Weight Watchers Program 2012
Weight Watchers Program: Payroll Stuffer

Sales Materials

About Our Products and Plan Designs

Consumer-Directed Health Plans
Dual Choice Healthcare Options - Large Group
Dual Choice Healthcare Options - Small Group
Group Dental Plans
Group Health Plan Designs (updated January 4, 2012)
Health Reimbursement Arrangement (HRA)
HSA: Health Savings Account
HSA: Integrated Health Savings Account Billing and Enrollment
Life and AD&D Insurance
Life and AD&D Quote Sheet
Managed Pharmacy Benefit Designs
Manley Services Healthcare FSA
PacificSource Optional Benefits

About Our Programs and Services

Condition Support Program
Coordination of Benefits
Cost Containment Through Care Management
First Health Network
Global Emergency Services from Assist America
Health Management with PacificSource
Health Manager and Biometric Screenings
InTouch for Employers
LifeTrac Transplant Network
Online Employee Wellness Communication Toolkit
PacificSource Network: Hospitals
PacificSource Network: Urgent Care
Prescription Discount Program
Spanish Language Services & Materials
Value-Added Programs & Services
Weight Management Resources for Members
Weight Management: Payroll Stuffer
Wellness Brown Bag Seminars

About PacificSource

About Us
Community Health Excellence Program
Community Service
Financial Performance
Idaho Client Testimonials
Operational Performance
Our Customers: Guistina Land and Timber Co.
Our History
Straight Talk About Healthcare Costs
The PacificSource Bottom Line
We're In It for the People

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Help your employees get engaged!

Our Workplace Wellness Toolkit includes posters, payroll stuffers, and newsletter articles you can use to promote healthy behaviors in your workplace.

Last updated 10/25/2011

Forms and Materials for Employers