Our office-space closures help ensure community and employee safety
In our effort to slow the spread of COVID-19, PacificSource office locations remain closed. Until further notice, we’re unable to accommodate any walk-in visitors. As always, our Customer Service team is glad to answer your questions by phone or email. Let us know how we can help!
Contact Us
In our effort to slow the spread of COVID-19, PacificSource office locations remain closed. Until further notice, we’re unable to accommodate any walk-in visitors. As always, our Customer Service team is glad to answer your questions by phone or email. Let us know how we can help!
Contact Us
Central Oregon, Eastern Oregon, and Mid-Columbia Gorge
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Coos County and Curry County
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Lane County
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Portland Metro Area
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Eastern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
PERSI Sick Leave Authorization Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Northern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
PERSI Sick Leave Authorization Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Southern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
PERSI Sick Leave Authorization Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Southwest Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
PERSI Sick Leave Authorization Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Yellowstone County Montana
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Clark County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Pierce County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form
Spokane County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2021 Enrollment Form
-
2021 Optional Dental Enrollment Form
-
Appointment of Representative Form
-
Auto Pay Request Form
-
CVS Pharmacy Order Form
-
Pharmacy Prior Authorization Form
-
Prior Prescription Drug Coverage Form
-
Producer of Record Change Request
-
Release of Health Information Form
-
Scope of Sales Appointment Confirmation Form