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  • Forms and Materials

    The documents on this page are in Adobe Acrobat PDF format. If you do not have Adobe Acrobat Reader on your computer, click here to download the free software.

  • General Information

  • Icon About PacificSource Administrators
    Icon COBRA Benefit Administration Flier
    Icon Flexible Spending Account Administration Flier
    Icon Health Reimbursement Arrangement (HRA) Administration Flier
    Icon PCORI Fee Information for Employers
    Icon Premium Only Plan (POP) Administration Flier
    Icon Transportation Fringe Benefit

  • For Employers

  • Icon COBRA Employer Administration Manual
    Icon COBRA Web Portal Tutorial
    Icon Employer Carrier Authorization Form
    Icon Newly Covered Employee/Spouse Form
    Icon Notice of a Qualifying Event
    Icon Notice of Dependent Qualifying Event
    Icon Special Plan Member (SPM) Information Form

  • FSA/HRA Materials for Employers

  • Icon Carryover Provision Amendment
    Icon FSA Enrollment Form
    Icon FSA Participant Termination Form
    Icon FSA Participant Termination Form (en Espanol)
    Icon FSA Structure Chart
    Icon HRA Enrollment and Change Form
    Icon HRA Plans at a Glance
    Icon HRA Standard Plans at a Glance
    Icon HRA Supplemental Plans at a Glance
    Icon Premium Only Plan (POP) Service Agreement

  • For Members | Cobra

  • Icon ACH Form
    Icon Addition of a Dependent Form
    Icon Contact Information Change Form
    Icon Social Security Disability Extension (SSDE) Form

  • FSA/HRA Forms for Members

  • Icon Authorization to Disclose PHI
    Icon Carryover Provision Amendment
    Icon Debit Card Receipt Submission Form
    Icon Debit Card Refund Submission Form
    Icon Dependent Care Recurring Expense Form
    Icon Direct Deposit - Request for Reimbursement from FSA or HRA
    Icon EasyPay Enrollment Form
    Icon Employee FSA Change Form
    Icon FSA Enrollment Form
    Icon FSA Enrollment Form (en Espanol)
    Icon FSA Expense Allocation Worksheet
    Icon Health Reimbursement Arrangement Opt-out Form
    Icon HRA Enrollment and Change Form
    Icon Letter of Medical Necessity
    Icon Request For Reimbursement - FSA and HRA
    Icon Request for Reimbursement - FSA or HRA (en Espanol)
    Icon Request For Reimbursement - Transportation and Parking

  • FSA/HRA Information for Members

  • Icon EasyPay Flier
    Icon Examples of Eligible Expenses - Dependent Care FSA
    Icon Examples of Eligible Expenses - General Purpose FSA
    Icon Examples of Eligible Expenses - Limited Purpose FSA
    Icon Examples of Eligible Expenses - Limited Scope FSA
    Icon FSA Participant Guide
    Icon FSA/HRA: Online Account Access for Participants
    Icon Grace Period FAQ
    Icon Healthcare Reform FAQ: Over-the-counter Medications
    Icon Manley Services is Now PacificSource Administrators
    Icon Obstetric and Prenatal Care Guidelines
    Icon Ortho Guidelines
    Icon Prepaid Benefits Card Flier
    Icon PSA: A Mobile App to Manage Your Reimbursement Accounts