Forms and Materials for
Our Members

The forms and materials available on this page are not specific to any particular plan. If you have questions about your plan's coverage, please check your benefit materials or contact our Customer Service Department.

Administrative Forms

Accident Report
Authorization to Use or Disclose PHI
Care Coordination Request	en Español
Dental Claim Form
Electronic Funds Transfer (EFT) Authorization
Employee Address or Name Change	en Español
Participating Provider Directory Request
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
Request Record Set Access

General Educational Materials

Auditing Claims to Manage Costs
Average Cost of Medical Care	en Español
Health Manager's Child Health Center
Health Resources for You and Your Family	en Español
How to Submit a Claim
International Travel	en Español
Making Sense of Third Party Recovery	en Español
Online Provider Directory
Privacy Policy	en Español
Rising Healthcare Costs: Information and Tips	en Español
Seven Ways to Become an Informed Healthcare Consumer	en Español

InTouch Login

Access your PacificSource account information 24/7.

Last updated 3/19/2009

Forms and Materials for Our Members

Administrative Forms

General Educational Materials

InTouch Login

Forms and Materials for
Our Members