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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

Manage Employee Coverage

Administrative Forms

2018 Group Enrollment Application and Waiver (Dental Only)
2018 Group Enrollment Application and Waiver (Medical/Dental)
Affidavit of Domestic Partnership
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
Individual Policy Change Form
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

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 (2017)
Medicare Part D Creditability Matrix (2018)
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), 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 4/16/2018

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