Idaho-Gateway-GraphicForms and Materials for Employers

The documents on this page were designed to help you manage your group’s coverage. 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.

Manage Your Group Coverage

Manage Employee Coverage

Administrative Forms

Affidavit of Domestic Partnership
Authorization to Use or Disclose PHIen Español
CHIP Noticeen Español
Common Ownership Confirmation Form
Coordination of Benefits Form
Designation of Authorized Representative
Disabled Dependent Certification
Employee Address or Name Changeen Español
Enrollment Application (Group Dental)
Enrollment Application (Small Group)en Español
Enrollment Confirmation - Member form (PCP)
Enrollment Confirmation - Member form (PCP-PCD)
ERISA: SPD Sample Wrap Template
Group Health Information Release
HSA - Member Enrollment Kit (with HSA Bank Application) (2016)
Individual Policy Change Form
Life and AD&D - Member Enrollment
Request Accounting of Disclosures
Request Record Set Access
Request to Amend a Designated Record Set
Restrict Record Set Access
Right Fit Selection Form Template
Termination of Dependent Coverage
Waiver of Coverageen Español
Work Confirmation

Claims and Medical Benefit Forms

Accident Report
Care Coordination Request
Claim Form - Dental
Prenatal Vitamin Home Delivery Order Form
Prescription Drug Claim Form

Continuation Coverage Forms

COBRA Initial Notice (Continuation Coverage Rights Under COBRA)
Continuation Election Form (Dental Only)
Continuation Election Form (Federal, Word format)en Español
Guide: PacificSource Model Notices

Medicare Part D Notices

Medicare Part D Creditability Matrix (2015)
Medicare Part D Creditability Matrix (2016)
Medicare Part D Creditability Matrix (2017)
Notice A (creditable) Sample Member Noticeen Español
Notice A (creditable): Employer Notice
Notice B (noncreditable) Sample Member Noticeen Español
Notice B (noncreditable): Employer Notice

Provider Nomination Forms

Advantage Dental
First Health Network
PacificSource (PSN), Prime, SmartHealth, and SmartChoice Networks

Plan Benefits and Information

Health and Wellness Programs

Online Tools

Payroll Inserts

InTouch for Employers

Access your PacificSource account information 24/7.

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.

Learn how to implement a successful workplace wellness program using our Winning at Wellness guide.

Get the background and regulation information you need for wellness program incentives with our new white paper, Understanding Health-contingent Wellness Incentives.

Last updated 11/7/2014