Documents & Forms
Search for a document by keyword, by filtering, or both. For questions about documents and forms specific to your plan and coverage, please contact Customer Service.
You can also browse our Medicaid members documents or our Medicare website.
41 results
About PacificSource Administrators
Debit Card Receipt Submission Form
Debit Card Refund Submission Form
Dependent Care Assistance Program (DCAP) Examples of Eligible and Ineligible Expenses
Direct Deposit Setup - Request for Reimbursement from FSA or HRA
FSA Grace Period FAQ
FSA Obstetric and Prenatal Care Guidelines
FSA Ortho Guidelines
FSA Structure Chart
FSA/HRA Medical mileage reimbursement worksheet
FSA/HRA Prepaid Benefits Card Employer Flier
Group Authorization Agreement for Recurring Electronic Fund Transfers (EFT) - PSA
Health Reimbursement Arrangement (HRA) Administration Flier
Health Reimbursement Arrangement Opt-out Form
How to access your FSA or HRA account online
How to access your FSA or HRA account online
HRA Plans at a Glance
HRA Standard Plans at a Glance
HRA Supplemental Plans at a Glance
Important Notice Regarding Unsubstantiated Debit Card Transactions
Letter of Medical Necessity for FSA/HRA
PCORI Fee Information for Employers
PSA: A Mobile App to Manage Your Reimbursement Accounts