Forms and Materials for Agents

Click on the categories below to download materials. Please feel free to contact our Boise Regional Office at (208) 342-3709 or (888) 492-2875 if you have a special request.

Brochures and Sales Materials

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

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

New Group Enrollment Forms

Agent Checklist for New Group Enrollment
Common Ownership Confirmation Form
Group Dental Enrollment Application
Group Health Information Release
Life and AD&D - Employer Application for Group Life
Life and AD&D - Member Enrollment
Request for Idaho Group Insurance (Master Application)
Short Form Add Dental
Waiver of Coverage	en Español
Work Confirmation

Administrative Forms

Administering Existing Business

Accident Report
Affidavit of Domestic Partnership
Agent of Record Appointment
Authorization to Use or Disclose PHI	en Español
Care Coordination Request	en Español
CHIP Notice	en Español
Coordination of Benefits Form
Designation of Authorized Representative
Direct Deposit for Commission Checks
Dual Choice Medical Plan Selection Form
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
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

Enrolling New Business

Agent Checklist for New Group Enrollment
Common Ownership Confirmation Form
Dual Choice Medical Plan Selection Form
Enrollment Application (Large Group 100+)
Enrollment Application (Mid-size Group 51-99)	en Español
Enrollment Application (Small Group)	en Español
Group Dental Enrollment Application
Group Health Information Release
HSA Member Enrollment Kit (with HSA Bank Application)
Life and AD&D - Employer Application for Group Life
Life and AD&D - Member Enrollment
Request for Idaho Group Insurance (Master Application)
Short Form Add Dental
Universal Application (for use after September 22, 2010)
Waiver of Coverage
Work Confirmation

Requesting Quotes

Group Health Information Release
Idaho Proposal Request
Idaho Proposal Request (Excel format) 11-8-11

Administering Continuation Coverage

Continuation Coverage Rights Under COBRA	en Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)	en Español

Individual Policy Materials

Affidavit of Domestic Partnership
BrightIdea Application Update
BrightIdea Brochure	en Español
BrightIdea Plans Sales Area Map
Electronic Funds Transfer (EFT) Authorization	en Español
Idaho Individual Application
Idaho Individual Application Update Form
Idaho Individual Parent Guardian Consent Form
SmartHealth Brochure	en Español

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

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

Medicare Part D 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