Forms and Fliers

Need a form or flier? Feel free to download the current versions of these PacificSource Administrators materials. Just click on the links below. The documents are Adobe Acrobat PDF format. If you do not have Adobe Acrobat Reader on your computer, you can download the software for free.

Forms

Accident & Injury Form
Enrollment Form
COBRA forms

The forms contain interactive fields so that you can complete them online. Once you have completed and signed the form, print it, and send it to us by mail or fax. Please note: You will only be able to save the completed form to your computer if you have Adobe Acrobat Professional.

Send Accident & Injury form to:
PO Box 70088, Springfield OR 97475-0105
Fax: 503.670.8263

Send Enrollment forms to:
13010 SW 68th Parkway, Suite 140, Tigard, OR, 97223
Fax: 503.598.0197

Fliers

Our fliers are currently being updated. If you need a specific flier or other information, please feel free to contact us.

Mental Health Parity FAQ