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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.

• COBRA Forms for Employers

• Employer Carrier Authorization Form

  Newly Covered Employee Spouse Form

  Notice of a Qualifying Event

  Notice of Dependent Qualifying Event

  Special Plan Member (SPM) Information Form

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• COBRA Forms for Members

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• ACH Form

  Addition of a Dependent Form

  Benefits Termination Form

  Contact Information Change Form

  Social Security Disability Extension (SSDE) Form

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• Flex Forms and Information for Employers

• FSA: The Smart Choice for Employers

  HRA Plans at a Glance

  HRA Standard Plans at a Glance

  HRA Supplemental Plans at a Glance

  HRA The Smart Solution for Idaho

  HRA The Smart Solution for Montana

  HRA The Smart Solution for Oregon

  HRA The Smart Solution for Washington

  Premium Only Plan Service Agreement

  Transportation Benefit Flier for Idaho Businesses

  Transportation Benefit Flier for Montana Businesses

  Transportation Benefit Flier for Oregon Businesses

  Transportation Benefit Flier for Washington Businesses

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• Flex Forms for Members

• Benny Receipt Submission Form

  Benny Refund Submission Form

  Direct Deposit Setup

  EasyPay Enrollment Form

  Employee FSA Change Form

  FSA Expense Allocation Worksheet

  Letter of Medical Necessity

  Request for Reimbursement from FSA or HRA

  Request for Reimbursement from Transportation Benefit

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• Flex Information for Members

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• Benny Card Flier

  EasyPay Flier

  Examples of Eligible Expenses

  FSA Users' Guide (11x17 Brochure Size)

  FSA Users' Guide (Letter Size)

  Grace Period FAQ

  Manley Services is Becoming PacificSource Administrators

  MyFlex Flier

  Obstetric and Prenatal Care Guidelines

  Ortho Guidelines

  OTC Changes Flier

  OTC FAQ