Documents & Forms
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356 results
2023 ID Individual and Family Brochure - Navigator
2023 ID Individual and Family Brochure - Voyager
2023 ID Individual and Family Dental Only Plan Comparison
2023 ID Individual and Family Medical Plan Comparison - Navigator
2023 ID Individual and Family Medical Plan Comparison - Voyager
2023 ID Individual and Family Plan Rates (Navigator)
2023 ID Individual and Family Plan Rates (Voyager)
2023 ID Large Group Brochure - Dental Only
2023 ID Large Group Brochure - Navigator
2023 ID Large Group Brochure - Voyager
2023 ID Large Group Master Application (Medical/Dental)
2023 ID Sample General Medical Limitations and Exclusions
2023 ID Small Group Brochure - Navigator
2023 ID Small Group Brochure - Voyager
2023 ID Small Group Dental Only Plan Comparison
2023 ID Small Group Master Application (Medical/Dental)
2023 ID Small Group Medical Plan Comparison - Navigator
2023 ID Small Group Medical Plan Comparison - Voyager
2023 Idaho Individual Dental Exclusions
2023 Idaho Small Group Dental Exclusions
2023 Idaho Small Group Dental Exclusions
2023 MT Individual and Family Brochure - Navigator
2023 MT Individual and Family Dental Only Plan Comparison
2023 MT Individual and Family Medical Plan Comparison - Navigator
2023 MT Individual and Family Plan Rates
2023 MT Large Group Brochure - Dental Only
2023 MT Large Group Brochure - Navigator
2023 MT Large Group Master Application (Medical/Dental)
2023 MT Small Group Brochure - Navigator
2023 MT Small Group Dental Only Plan Comparison
2023 MT Small Group Master Application (Medical/Dental)
2023 MT Small Group Medical Plan Comparison - Navigator
2023 OR Individual and Family Brochure - Navigator
2023 OR Individual and Family Dental Only Plan Comparison
2023 OR Individual and Family Medical Plan Comparison - Navigator
2023 OR Individual and Family Plan Rates
2023 OR Large Group Brochure - Dental Only
2023 OR Large Group Brochure - Navigator
2023 OR Large Group Brochure - Voyager
2023 OR Large Group Master Application (Medical/Dental)
2023 OR Small Group Brochure - Navigator
2023 OR Small Group Brochure - Voyager
2023 OR Small Group Dental Only Plan Comparison
2023 OR Small Group Master Application (Medical/Dental)
2023 OR Small Group Medical Plan Comparison - Navigator
2023 OR Small Group Medical Plan Comparison - Voyager
2023 Quality Pool Distribution Plan - Central Oregon
2023 Quality Pool Distribution Plan - Columbia Gorge
2023 Quality Pool Distribution Plan - Lane
2023 Quality Pool Distribution Plan - Marion and Polk
2023 WA Health Plan Disclosure
2023 WA Individual and Family Plan Rates
2023 WA Large Group Brochure - Navigator
2023 WA Large Group Brochure - Voyager
2023 WA Large Group Dental Only Brochure
2023 WA Large Group Master Application (Medical/Dental)
2023 WA Small Group Brochure - Navigator
2023 WA Small Group Brochure - Voyager
2023 WA Small Group Dental Only Plan Comparison
2023 WA Small Group Master Application (Medical/Dental)
2023 WA Small Group Medical Plan Comparison - Navigator
2023 WA Small Group Medical Plan Comparison - Voyager
2024 Employer Health Plans Brochure
2024 ID Sample General Medical Limitations and Exclusions
2024 ID Small Group Master Application (Medical/Dental)
2024 Idaho Individual Dental Exclusions
2024 MT Individual and Family Dental Only Plan Comparison
2024 MT Individual and Family Medical Plan Comparison - Navigator
2024 MT Individual and Family Plan Rates
2024 MT Large Group Brochure - Dental Only
2024 MT Large Group Master Application (Medical/Dental)
2024 MT Large Group Medical Plan Comparison - Navigator
2024 MT Small Group Dental Only Plan Comparison
2024 MT Small Group Master Application (Medical/Dental)
2024 MT Small Group Medical Plan Comparison - Navigator
2024 WA Health Plan Disclosure
2024 WA Individual and Family Plan Rates
2024 WA Small Group Dental Only Plan Comparison
About PacificSource Administrators
ACA Reporting Requirements Guide
Accident Report (Medical Service Questionnaire)
Active&Fit Direct™ Fitness Center Program
Advantage Dental Network Nomination
Aetna Signature Administrators Nomination
Attestation of Eligibility
Auto-recoupment enrollment form
Balance Billing Protection Notice for ID
Balance Billing Protection Notice for MT
Balance Billing Protection Notice for OR
Balance Billing Protection Notice for WA
Behavioral Health Directed Payment Guidance
Behavioral Health Navigation Team
Behavioral Health: Admission Notification Form
Behavioral Health: Preauthorization Request Form for ABA Services
CCO Region Afghan Refugee Interpreter Vendors Guide
CHE Application Guide
CHE Budget Form
CHE Collaborations 2019-2020
CHE Flier
Claim Form - Dental
Claim Form - Medical
Claim Status Request
Claims Research Request Form
COBRA Addition of a Dependent Form
COBRA Benefit Administration Flier
COBRA Contact Information Change Form
COBRA Election Form Federal Template
COBRA Electronic Debit Account (EDA-ACH) Enrollment-Change Form
COBRA Employer Administration Manual
COBRA Employer Carrier Authorization Form
COBRA Initial Notice Template
COBRA Newly Covered Employee-Spouse Form
COBRA Notice of a Qualifying Event
COBRA Notice of Dependent Qualifying Event
COBRA Quick Guide FAQ
COBRA Social Security Disability Extension (SSDE) Form
COBRA Special Plan Member (SPM) Information Form
COBRA Web Portal Tutorial
Code of Conduct
Common Ownership Form
Community Health Worker Certification Instructions
Community Solutions covered over-the-counter medications
Community Solutions Prior Authorization Criteria
Compliance and Program Integrity Plan
Contact Information Request Form
Contested Refund Form
Continuation of Coverage Laws FAQ for Members (Oregon only)
Contracted Doula Billing FAQ
Coordination of Benefits
Corrected Claim Form (Medicaid)
Corrected Dental Claim Form
Corrected Medical Claim Form
COVID-19 Benefit and Reimbursement Policy FAQ
COVID-19 Provider Relief Plan FAQ
Credentialing - Add a Hospital Based Provider - Provider Information Request Form - ID MT
Credentialing - Add a Hospital-based Provider - OR WA
Credentialing - Interest Packet for Facilities and Hospitals - OR
Credentialing - Interest Packet for Providers - OR
Credentialing - Recredentialing Application for Providers - OR
Credentialing Application for Facilities and Hospitals - ID MT
Credentialing Application for Facilities and Hospitals - OR WA
Credentialing Application for Providers - ID MT
Credentialing Application for Providers - OR with criteria checklist
Credentialing Application for Providers - WA
Credentialing Application Rights
Credentialing Criteria
Debit Card Receipt Submission Form
Debit Card Refund Submission Form
Dental Claims Referral Form - Dental Essentials
Dental Provider Contracting Interest Form
Dependent Care Assistance Program (DCAP) Examples of Eligible and Ineligible Expenses
Designation of Authorized Representative
Diagnostic Imaging Prior Authorization List
Direct Deposit Setup - Request for Reimbursement from FSA or HRA
Doctor Visit Guide
Doula Certification Instructions
Drug List - Prior Authorization Criteria
Drug List - Step Therapy Criteria
EFT Payment FAQ
Electronic Remittance Advice (835) and EFT Authorization Agreement
Employer Exemption Certification for Religious or Moral Objections - WA
Flexible Spending Account Administration Flier
FSA Grace Period FAQ
FSA Obstetric and Prenatal Care Guidelines
FSA Ortho Guidelines
FSA Structure Chart
FSA/HRA Medical mileage reimbursement worksheet
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT)
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT) - Self-funded
Group Coverage Continuation Election Form (WA small group)
Group Identification Form - MT, OR, WA
Health and Wellness Journey Map
Health Care Interpreter (HCI) Guidelines and FAQ
Health Education Reimbursement Form
Health Reimbursement Arrangement (HRA) Administration Flier
Health Reimbursement Arrangement Opt-out Form
Health Related Services Flex Fund FAQ
Health Related Services Flex Fund Request Form
HRA Plans at a Glance
HRA Standard Plans at a Glance
HRA Supplemental Plans at a Glance
Important Notice Regarding Unsubstantiated Debit Card Transactions
Individual Policy Change Form
InTouch for Providers Resource Guide
Language Access Plan
Large Group Census for ID
Large Group Census for MT
Large Group ID Self-Funded Dental Flier
Large Group MT Self-Funded Dental Flier
Large Group OR Self-Funded Dental Flier
Large Group Request for Quote (census form) - WA
Large Group WA Self-Funded Dental Flier
Letter of Medical Necessity for FSA/HRA
LineFinder FAQ
Medicaid Grievance and Appeals System – Grievances, Appeals and Hearings
Medicaid Grievance and Appeals System – Member Information and Education Requirements
Medicaid Grievance and Appeals System – Notice of Adverse Benefit Determination
Medicaid Provider Enrollment FAQ
Medicaid Provider Validation Application
Medicare Health Outcomes Survey Measures
Medicare Notice A (creditable) Sample Member Notice
Medicare Notice B (noncreditable) Sample Member Notice
Medicare Part D Creditable Coverage FAQ
Medicare Part D Employer Creditability Notice
Medicare Part D ID 2022 Creditability Matrix
Medicare Part D ID 2023 Creditability Matrix
Medicare Part D MT 2022 Creditability Matrix
Medicare Part D MT 2023 Creditability Matrix
Medicare Part D OR 2022 Creditability Matrix
Medicare Part D OR 2023 Creditability Matrix
Medicare Part D WA 2022 Creditability Matrix
Medicare Part D WA 2023 Creditability Matrix
Medication Restriction Request Form
Member Appeal Form
Member Guide (for members with dental-only plans)
Member Support Specialist Flier
Mobile Dentistry and Teledentistry Explained
Naloxone for Opioid Safety
Navigator Network Flier - Idaho
Navigator Network Flier - Montana
Navigator Network Flier - Oregon
Navigator Network Flier - Washington
New and Emerging Technologies: Coverage Status
On-site Flu Shot Clinic Provider List
Opioid Medication Coverage FAQ (Commercial)
Opioid Medication Coverage FAQ (Medicaid)
Opioid Member Education Overview
Oral Health Integration FAQ
Ordering, Referring, Prescribing and Attending FAQ
Oregon Health Plan (OHP) Dental Benefit System
Oregon Organization Medicaid ID Application
Oregon Provider Medicaid ID Application
Oregon Request for Confidential Communication
PacificSource CLAS Standards
PacificSource Foundation 2021 Impact Report
Parent/Guardian Information Form
PCORI Fee Information for Employers
PCP Assignment FAQ
Peer Support Specialist Certification Instructions
Peer Wellness Specialist Certification Instructions
Personal Health Navigator Instructions
Pharmacy Network for ID, MT, OR, and WA
Pharmacy Network for ID, MT, OR, and WA (Excel format)
Pharmacy Prior Authorization Request Form (Medicaid)
Pharmacy Product Guidelines FAQ
Premium Only Plan (POP) Administration Flier
Premium Only Plan (POP) Service Agreement
Premium Only Plan (POP) Service Agreement - Idaho Only
Prescription Drug Claim Form
Prior Authorization Checklist - Blepharoplasty
Prior Authorization Checklist - Bone Growth (Electronic and Ultrasonic) Stimulators
Prior Authorization Checklist - Dental as Medical
Prior Authorization Checklist - Instrumented Spinal Surgery
Prior Authorization Checklist - Reduction Mammoplasty
Prior Authorization FAQ (Medicaid)
Prior Authorization Request Form
Prior Authorization Request Form (Medicaid)
Prior Authorization/Medication Exception Request Form
Proposal Request: Fully Insured (Large Group 51-99) - WA
Proposal Request: Fully-Insured (Large Group 51-99) - ID
Prospective Agent Appointment Form
Provider Access Standards
Provider Appeal Form
Provider Capacity
Provider Contracting Interest Form
Provider Enrollment Agreement
Provider Hepatitis C Case Management Form
Provider Information Request - ID and MT
Provider Information Request - OR and WA
Provider Manual
Provider Network Contact List
Provider Nomination Form
Provider Offshore Operations Attestation
Provider Peer to Peer FAQ
Provider Teledentistry FAQ
Provider Tips and Tricks Clean Claims
PSA: A Mobile App to Manage Your Reimbursement Accounts
Quick Guide to Becoming a Healthcare Interpreter
Quote Request for Small Groups
Recredentialing Criteria
Renewal Confirmation Form
Request a copy of my health information
Request Accounting of Disclosures
Request for Quote Large Group (51+) - MT
Request For Reimbursement - Transportation and Parking
Request to correct or add to my health records
Request to restrict access to my health information
Self-Funded Administrative Solutions
Short Form Health Statement (required if no claims experience submitted) - MT
SmartAlliance Network Flier
Smoking Abstinence FAQ
Split Carrier Waiver of Coverage
Telemedicine and Telehealth FAQ
Traditional Health Worker Reporting Template
Traditional Health Workers FAQ
Transportation and parking benefit debit card
Transportation Fringe Benefit
Universal Application (Mid-size Group 51-99) - ID
Value Based Preventive Drug List
Voyager Network Flier
Weight Management with WW
Winning at Wellness Workbook