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Oregon-Gateway-GraphicForms and Materials for Agents

Click on the categories below to download materials. Please feel free to contact your PacificSource regional office if you have a special request. 

 

Brochures and Sales Materials

About our products and plan designs:

Chiropractic and Alternative Care Benefits
Consumer-Directed Health Plans
Dental Advantage Plans
Dual Choice Healthcare Options - Large Group
Dual Choice Healthcare Options - Small Group
Group Dental Plans
Group Health Plan Designs
Health Reimbursement Arrangement (HRA)
Health Savings Account (HSA)
Healthcare Savings Vehicles at a Glance
HSA FAQ
Integrated Health Savings Account Billing and Enrollment
Life and Disability Quote Sheet
Life and Disablilty Insurance
Local Bank for Your HSA
Managed Pharmacy Benefit Designs
Manley Services Healthcare FSA
PacificSource Network: Hospitals
PacificSource Network: Urgent Care
PacificSource Optional Benefits
Short Term Medical Coverage

About our programs and services:

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 Administrators
InTouch for Agents
LifeTrac Transplant Network
Online Employee Wellness Communication Toolkit
Online Enrollment at PacificSource.com
Online Quoting through InTouch for Agents
Prescription Discount Program
Spanish Language Services and Materials
Value-Added Programs and Services
Wellness Brown Bag Seminars

About PacificSource:

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

New Group Enrollment Forms

Administrative Forms

Enrolling New Business

Agent Checklist for New Group Enrollment
Dual Choice Medical Plan Selection Form
Group Dental Enrollment Application
Group Health-Dental Enrollment Application
Group Profile Form
HRA Account Setup Worksheet
HSA Integrated Billing Employer Packet
HSA Member Enrollment Kit (with HSA Bank Application)
Request for Oregon Group Insurance (Master Application)
Waiver of Coverage

Requesting Quotes

Common Ownership Confirmation Form
Group Profile Form FAQ
Oregon Standardized Group Profile Form
Owners Work Confirmation Form
Proposal Request - Groups with 2-50 Employees
Proposal Request - Groups with 51+ Employees

Administering Existing Business

Accident Report
Affidavit of Domestic Partnership
Agent of Record Appointment
Authorization to Use or Disclose PHI
Care Coordination Requesten Español
CHIPRA Noticeen Español
Dental Claim Form
Direct Deposit for Commission Checks
Disabled Dependent Certification
Employee Address or Name Changeen Español
Group Authorization Agreement for Recurring Electronic Fund Transfers
Group Change Guidelines
Guide: PacificSource Model Notices
Plan Administrator Manual
Prenatal Vitamin Home Delivery Order Form
Prescription Drug Claim Form
Provider Nomination Form–Advantage
Provider Nomination Form–First Health Network
Provider Nomination Form–IPN
Provider Nomination Form–PacificSource Network
Renewal Confirmation Form
Request Record Set Access
Termination of Dependent Coverage

Administering Continuation Coverage

Additional Election Notice Packet
CMS ARRA Appeal Form
COBRA Extended Election Period Notice Packet
COBRA General Notice Packet
COBRA New Election Period Notice Packet
COBRA Supplemental Notice Packet
COBRA_Subsidy_Extension_Notice
Continuation Coverage Rights Under COBRAen Español
Continuation Election Form (Dental Only)
Continuation Election Form (Federal)en Español
Continuation Election Form (State)
DOL ARRA Appeal Form
FAQ: COBRA Provisions of the ARRA
FAQ: Oregon State Continuation
Oregon State Continuation Packet

Individual Policy Materials

Elect Plans

Agent iStore Quick Reference Guide
Application Tips: Reviewing Your Client's Individual Application
Elect Application Tips for Agents
Elect Brochureen Español
Elect Individual and Family Plan Change Matrix
Elect Individual Policy Change Form
Elect Policy Application
Elect Policy Premium Rates (January 1, 2010)
Elect Trifold Brochure: Quality Health Plans (January 1, 2010)en Español
Electronic Funds Transfer (EFT) Authorization
Individual Sales FAQ: Answers to Your Questions
Top Reasons to Sell Elect Individual and Family Plans
Which Individual Health Plan is Right for You?

Short Term Medical Plans

Short Term Medical Application
Short Term Medical Coverage Brochure
Short Term Medical Coverage Flier
Short Term Medical Limitations and Exclusions
Short Term Medical Plan Options
STM Payroll Insert
STM Plan Premium Rates (effective October 1, 2009)

Member Materials

General Education

Auditing Claims to Manage Costs
Average Cost of Medical Careen Español
Health Manager's Child Health Center
Health Resources for You and Your Familyen Español
How to Submit a Claim
International Travelen Español
Making Sense of Third Party Recoveryen Español
Online Provider Directory
Privacy Policyen Español
Rising Healthcare Costs: Information and Tipsen Español
Seven Ways to Become an Informed Healthcare Consumeren Español

Plan Benefits

Auditing Claims to Manage Costs
Average Cost of Medical Care
Benny MasterCard
Dental: How to Maximize Your Dental Benefitsen Español
Diabetes Benefitsen Español
Health Resources for You and Your Family
Healthcare Benefits When Travelingen 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
Life Events
Mail Order Pharmacy Options for Prescription Drugsen Español
Mail Order Pharmacy Options Payroll Insert
Making Sense of Third Party Recovery
Maternity Benefitsen Español
Online Provider Directory
Privacy Policy
Rising Healthcare Costs: Information and Tips
Seven Ways to Become an Informed Healthcare Consumer
Transplant Travel Benefit
Vision Benefitsen Español

Value-Added Programs and Services

Accordant Care Rare Disease Programen Español
Chronic Disease Self-Management Program
Expectations: A Free Prenatal Programen Español
Expectations: Payroll Stuffer
First Health Networken Español
Free & Clear Quit for Life Program (Tobacco Cessation)en Español
Global Emergency Services Provided by Assist Americaen Español
Global Emergency Services Tri-fold Brochure
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 Classesen Español
InTouch and Health Manager Payroll Insert
InTouch: Online Access to Your Information
Member Guideen Español
PacificSource Extras (for groups with 2 to 50 employees)en Español
PacificSource Extras (for groups with 51 or more employees)en Español
PacificSource Extras (for short term medical plan members)
PacificSource Extras: Payroll Stuffer
Prescription Discount Program (plans with prescription drug coverage)en Español
Prescription Discount Program (plans without prescription drug coverage)en Español
WebMD Lifestyle Improvement Programs
Weight Watchers Pilot Program
Weight Watchers Pilot Program: Payroll Stuffer

Medicare Part D Notices

InTouch Account Help

InTouch Login

Access your PacificSource account information 24/7.

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Last updated 4/10/2009
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