Forms

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

Prescription Drug Claim Form

Accident & Injury Form - requires a signature

Authorization to Disclose Protected Health Information - requires a signature

COBRA forms

How to Submit Your Form

The forms are interactive, so you can complete them online. Once you have completed the form, please 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 your completed forms to:
PacificSource Administrators
PO Box 70088, Springfield OR 97475-0105
Fax: (503) 670-8263