About PacificSource Administrators

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Information

Forms and Materials

Strategic Partnerships and Technology

Forms and Materials

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General Information

COBRA Benefit Administration Flier

Flexible Spending Account Administration Flier

Health Reimbursement Arrangement (HRA) Administration Flier

PCORI Fee Information for Employers

Premium Only Plan (POP) Administration Flier

Transportation Fringe Benefit

For Employers

COBRA Employer Administration Manual

COBRA Web Portal Tutorial

Employer Carrier Authorization Form

Newly Covered Employee/Spouse Form

Notice of a Qualifying Event

Notice of Dependent Qualifying Event

Special Plan Member (SPM) Information Form

FSA/HRA Materials for Employers

Carryover Provision Amendment

FSA Enrollment Form

FSA Participant Termination Form

FSA Participant Termination Form (en Espanol)

FSA Structure Chart

HRA Enrollment and Change Form

HRA Plans at a Glance

HRA Standard Plans at a Glance

HRA Supplemental Plans at a Glance

Premium Only Plan (POP) Service Agreement

For Members | Cobra
ACH Form
Addition of a Dependent Form
Contact Information Change Form
Social Security Disability Extension (SSDE) Form
FSA/HRA Forms for Members

Authorization to Disclose PHI

Carryover Provision Amendment

Debit Card Receipt Submission Form

Debit Card Refund Submission Form

Dependent Care Recurring Expense Form

Direct Deposit - Request for Reimbursement from FSA or HRA

EasyPay Enrollment Form

Employee FSA Change Form

FSA Enrollment Form

FSA Enrollment Form (en Espanol)

FSA Expense Allocation Worksheet

Health Reimbursement Arrangement Opt-out Form

HRA Enrollment and Change Form

Letter of Medical Necessity

Request For Reimbursement - FSA and HRA

Request for Reimbursement - FSA or HRA (en Espanol)

Request For Reimbursement - Transportation and Parking

FSA/HRA Information for Members

EasyPay Flier

Examples of Eligible Expenses - Dependent Care FSA

Examples of Eligible Expenses - General Purpose FSA

Examples of Eligible Expenses - Limited Purpose FSA

Examples of Eligible Expenses - Limited Scope FSA

FSA Participant Guide

FSA/HRA: Online Account Access for Participants

Grace Period FAQ

Healthcare Reform FAQ: Over-the-counter Medications

Manley Services is Now PacificSource Administrators

Obstetric and Prenatal Care Guidelines

Ortho Guidelines

Prepaid Benefits Card Flier

Prospective Business

Information

Forms and Materials

General Information

For Employers

FSA/HRA Materials for Employers

For Members | Cobra

FSA/HRA Forms for Members

FSA/HRA Information for Members