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    My health insurance is through PacificSource Health Plans.

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  • Health Insurance Forms

    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.

  • Icon Accident and Injury Form
    Use this form to report an accident or injury.
     
    Icon Authorization to Disclose PHI (protected health information)
    Use this form to grant a person or entity legal permission to access your protected health information. For example, if you think you might need to call on behalf of a family member, it's a great idea to fill this out and send it now, before you need it. 
     
    Icon Authorization to Disclose PHI (protected health information) (en Espanol)
    Icon Caremark Getting Started with Mail Service
    Learn how to get started using Caremark Mail Service.
     
    Icon Caremark Mail Order Form
    Use this form to sign up for Caremark mail service. Check your ID card to be sure your plan uses Caremark before using this form. 
     
    Icon Express Scripts Mail Order Form
    Use this form to sign up for Express Scripts mail order service. Check your ID card to be sure your plan uses Express Scripts before using this form.
     
    Icon Mail Order Pharmacy Options
    If your employer group health plan includes prescription drug coverage with CVS Caremark, you can use our convenient mail order service for your daily or long-term medications.
     
    Icon Mail Order Pharmacy Options (en Espanol)

    Opciones de Farmacias con Pedidos de Entrega a Domicilio - Si su plan de salud de PacificSource incluye una cobertura de medicamentos de prescripción, usted puede utilizar nuestro práctico servicio de entregas a omicilio para surtir sus edicamentos de uso diario o de largo plazo.

    Icon Prescription Drug Claim Form
    Use this form to submit a claim for a prescription drug.