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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 New Rules for Mid-Year Election Changes under Cafeteria Plans
    Icon PCORI Fee Information for Employers
    Icon Premium Only Plan (POP) Administration Flier
    Icon Transportation Fringe Benefit

  • Account 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
    Icon Premium Only Plan (POP) Service Agreement - Idaho Only

  • COBRA Materials for Employers

  • Icon COBRA Employer Administration Manual
    Icon COBRA Quick Guide FAQ
    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

  • Health Insurance Materials for Members

    Mail Order Pharmacy Options (en Español)

  • Icon Accident and Injury Form
    Icon Authorization to Disclose PHI (protected health information)
    Icon Authorization to Disclose PHI (protected health information) (en Espanol)
    Icon Caremark Getting Started with Mail Service
    Icon Caremark Mail Order Form
    Icon Express Scripts Mail Order Form
    Icon Prescription Drug Claim Form

  • COBRA Forms for Members

  • 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 Setup - 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 Medical mileage reimbursement worksheet
    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
    Icon Transportation and parking benefit debit card

  • Spanish Documents

  • Icon Acceso a Cuentas en Línea para Participantes (Online Account Access for Participants)
    Icon Cuenta de Gastos Flexibles de Salud (HRE) de Propósito General (Examples of Eligible Expenses - General Purpose FSA)
    Icon Cuenta de Gastos Flexibles de Salud de Alcance Limitado (LSFSA) (Examples of Eligible Expenses - Limited Scope FSA)
    Icon Cuenta de Gastos Flexibles de Salud de Propósito Limitado (LFSA) (Examples of Eligible Expenses - Limited Purpose FSA)
    Icon Depósito directo - Formulario de Autorización de Depósito Directo / Transferencia Electrónica de Fondos (EFT) (Direct Deposit/EFT setup)
    Icon Formulario de Cambio de la Cuenta de Gastos Flexibles (FSA) para Empleados (Employee FSA Change Form)
    Icon Formulario de Gastos Recurrentes para el Cuidado de Dependientes (Dependent Care Recurring Expense Form)
    Icon Formulario de Inscripción a EasyPay (EasyPay Enrollment Form)
    Icon Formulario de Inscripción en la Cuenta de Gastos Flexibles (FSA) para Empleados (FSA Enrollment Form)
    Icon Formulario de Inscripción y Cambio de la Cuenta de Reembolso de Salud (HRA) (HRA Enrollment and Change Form)
    Icon Guía del Participante Cuentas FSA (FSA Participant Guide)
    Icon Hoja de Trabajo para Adjudicación de Gastos de la Cuenta FSA (FSA Expense Allocation Worksheet)
    Icon MÁS ingresos para gastar para usted o su familia (Tax Savings Poster)
    Icon Programa de Asistencia para el Cuidado de Dependientes (DCAP) (Examples of Eligible Expenses - Dependent Care FSA)
    Icon PSA: Una Aplicación Móvil para Manejar Sus Cuentas de Reembolso (PSA: A Mobile App)
    Icon Tarjeta de Débito de Beneficios (Benefit Debit Card Flier)
    Icon Utilice la Opción EasyPay para Recibir Reembolsos Sin Esfuerzo (EasyPay flier)

  • Healthcare Reform

  • Icon ACA Checklist for Employers with HRAs and FSAs
    Icon Employer Funded FSAs Must Modify Employer Contribution
    Icon Federal Model Notice Employer Cover Letter
    Icon Federal Model Notice Member FAQ
    Icon Federal Model Notice of Marketplace
    Icon Medicare D (creditable) PSA Employer Notice
    Icon Medicare D Sample Member Notice
    Icon Mid-year Election Plan Change Form
    Icon New Rules for Mid-Year Election Changes
    Icon PCORI Fee Information for Employers