Click to go to PacificSource Administrators home page
  • Agents | Employers | Providers | News | About Us | Contact Us

    My health insurance is through PacificSource Health Plans.

  • Health Insurance | FSA/HRA Benefits | COBRA Benefits   

  • Login: InTouch

  • Tools

    InTouch

    File a Claim

    Find a Pharmacy

    Find a Provider 

    Information

    Forms

    Preauthorization

    Privacy and HIPAA

     

  • Health Insurance Forms

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

    Mail Order Pharmacy Options

    Mail Order Pharmacy Options (en Espanol)

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