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

Manage Employee Coverage

Administrative Forms

2016 Group Enrollment Application (all size groups)
2016 Group Enrollment Application (Dental Only)
Affidavit of Domestic Partnership
Authorization to Use or Disclose PHIen Español
CHIP Noticeen Español
Coordination of Benefits Form
Designation of Authorized Representative
Disabled Dependent Certification
Employee Address or Name Changeen Español
Enrollment Confirmation - Member form (PCP)
Enrollment Confirmation - Member form (PCP-PCD)
ERISA: SPD Sample Wrap Template
HSA - Member Enrollment Kit (with HSA Bank Application) (2016)
HSA - Preferred HSA Member Enrollment Kit (flier only)
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
Termination of Dependent Coverage

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

First Health Network
PacificSource (PSN), Prime, 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 11/7/2014