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
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2020 Enrollment Form
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2020 Optional Dental Enrollment Form
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2021 Enrollment Form
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2021 Optional Dental Enrollment Form
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Appointment of Representative Form
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Auto Pay Request Form
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CVS Pharmacy Order Form
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Pharmacy Prior Authorization Form
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Prior Prescription Drug Coverage Form
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Producer of Record Change Request
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Release of Health Information Form
-
Sales Appointment/Scope of Appointment Form
Coos County and Curry County
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Lane County
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
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2020 Essentials 2 Plan
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2020 Essentials Rx 36 Plan
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2020 Essentials Rx 41 (LN) Plan
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2020 Explorer 8 Plan
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2020 Explorer Rx 4 Plan
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2020 Essentials Rx 803 Plan
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2021 Explorer Rx 4 Plan
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2021 Explorer 8 Plan
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2021 Essentials Rx 41 Plan
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2021 Essentials Rx 36 Plan
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2021 Essentials 2 Plan
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2021 Essentials Rx 803 Plan
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Portland Metro Area
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Eastern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Northern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Southern Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Southwest Idaho
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Yellowstone County Montana
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Clark County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Pierce County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form
Spokane County Washington
Brochures & Fliers
Summary of Benefits (SB)
Evidence Of Coverage (EOC)
Annual Notice of Change (ANOC)
Forms
-
2020 Enrollment Form
-
2020 Optional Dental Enrollment Form
-
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
-
Sales Appointment/Scope of Appointment Form