Forms and Materials for Agents

Click on the links below to download materials. You are welcome to contact our Helena Regional Office at (406) 422-1008 or (855) 422-1008 if you have a special request.

Brochures and Sales Materials

About PacificSource

Community Health Excellence Program

Financial Performance

Operational Performance

Straight Talk About Healthcare Costs

About Our Products and Plan Designs

Group Health Plan Designs

Group Optional Benefits (with dental)

Group Optional Benefits (without dental)

HSA: Health Savings Account

HSA: Integrated Health Savings Account Billing and Enrollment

Life and AD&D Insurance

Life and AD&D Quote Sheet

PacificSource Network: Hospitals

PacificSource Network: Urgent Care

About Our Programs and Services

Condition Support Program

Value-Added Programs and Services

Weight Management Resources for Members

Requesting Quotes

Request for Quote (Group 2-50, NFIB, and 51-99 health statement underwritten)

Request for Quote (51+ eligible, claims experience required)

Medical-Dental Enrollment Application (Group 2-50)

Medical-Dental Enrollment Application (Group 51+)

Waiver of Coverage

New Group Enrollment Forms

Dual Choice Medical Plan Selection Form

Group Authorization Agreement for Electronic Fund Transfers

Group Master Application

Group Dental Enrollment Application

Group Medical-Dental Enrollment Application (Group 2-50)

Group Medical-Dental Enrollment Application (Group 51+)

HSA Member Enrollment Kit (with HSA Bank Application)

Life and AD&D - Employer Application for Group Life

Life and AD&D - Member Enrollment

Waiver of Coverage

Administrative Forms

Authorization to Use or Disclose PHI

Care Coordination Request

Direct Deposit for Commission Checks

Dual Choice Medical Plan Selection Form

Renewal Confirmation

Renewal Confirmation - New West

Individual Policy Materials

Electronic Funds Transfer (EFT) Application

Individual and Family Plan Application

Individual Policy Change Form

Individual and Family Plan Rates (plans beginning January 1 - March 30, 2013)

Individual and Family Plan Rates (plans beginning April 1 - June 30, 2013)

Individual and Family Plan Rates (plans beginning July 1, 2013 - September 30, 2013)

Individual and Family Plan Rates (plans beginning October 1, 2013 - December 31, 2013)

Individual and Family Plan Brochure

Individual and Family Plan Application Tips for Agents

Individual Sales FAQ: Answers to your Questions

Top Reasons to Sell Individual and Family Plans

Member Materials

General Education

Auditing Claims to Manage Cost

Average Cost of Medical Care

Doctor Office Visit Guide

Health Manager's Child Health Center

Online Provider Directory

Preventive Care: Understanding Your Benefits - Montana

Rising Healthcare Costs: Information and Tips

Seven Ways to Become an Informed Healthcare Consumer

Plan Benefits

Diabetes Benefits	en Español
Healthcare Benefits When Traveling
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
Maternity Benefits
Transplant Travel Benefit

Value-Added Programs and Services

Global Emergency Services Provided by Assist America
Global Emergency Services Tri-fold Brochure
GlobalFit Discounted Gym Membership Program
Hospital-Based Education Classes
InTouch: Online Access to Your Information
InTouch and Health Manager Payroll Stuffer
Jenny Craig
Member Guide	en Español
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

InTouch Login

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Member Login

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Employers, Agents:

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Providers:

Registration Information

Questions?

You’re always welcome to contact us!

PacificSource Sales and Service Representatives

PacificSource Administrators, Inc.

Last updated 5/6/2013