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Forms 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

2018 Group Master Application (Dental Only)
2018 Group Master Application (Medical/Dental)
2018 Montana Large Group Brochure
2018 Montana Large Group Dental-only Brochure
2018 Montana Small Group Brochure
2018 Montana Small Group Brochure - Dental Only
2018 Voluntary Dental Brochure
2019 Montana Large Group Brochure
2019 Montana Large Group Brochure - Dental Only
2019 Montana Self-Funded Dental Brochure
2019 Montana Small Group Brochure
2019 Montana Small Group Brochure - Dental Only
2019 Montana Small Group Medical Plan Comparison
2019 Sample Limitations and Exclusions (Medical)
2019 Voluntary Dental Brochure
Agent of Record Appointment
Employer Manual
ERISA: SPD Sample Wrap Template
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Owners Work Confirmation Form
Renewal Confirmation Form

Manage Employee Coverage

Administrative Forms

2018 Group Enrollment Application and Waiver (Dental Only)
2018 Group Enrollment Application and Waiver (Medical/Dental)
2019 Group Enrollment Application and Waiver (Medical/Dental)
Authorization to Use or Disclose PHIen Español
CHIP Notice
Coordination of Benefits Form
Designation of Authorized Representative
Disabled Dependent Certification
Employee Address or Name Changeen Español
ERISA: SPD Sample Wrap Template
Request Accounting of Disclosures
Request Record Set Access
Request to Amend a Designated Record Set
Restrict Record Set Access
RightFit Plan and PCP Selection Formen Español
Termination of Dependent Coverage

Claims and Medical Benefit Forms

Care Coordination Request
Claim Form - Dental
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

Employer Notice
Medicare Part D Creditability Matrix (2018)
Medicare Part D Creditability Matrix (2019)
Medicare Part D Creditable Coverage FAQ
Notice A (creditable) Sample Member Noticeen Español
Notice B (noncreditable) Sample Member Noticeen Español

Provider Nomination Forms

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

Plan Benefits and Information

Health and Wellness Programs and Information

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 4/16/2018

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