Forms & Documents
HIPAA Forms
HIPAA
Disclosure Authorization PacFed or the Carrier may request that this
form be completed when you request private health information be released
to someone other than yourself, your spouse or your adult children.
HIPAA
Privacy Notice This notice explains the participants' rights under the
HIPAA Privacy Rules.
Marketing
Vision
Brochure Davis Vision Brochure (4 Pages)
DeltaCare
(DHMO) four (4) page brochure
Delta
Preferred (PPO) four (4) page brochure
Form
Request Request for multiple forms
Guidelines
for Agents and Producers Producers Underwriting and Administrative Guidelines
New
Case Checklist Check list to aid in the enrollment of a new group
Employee Forms
Enrollment
Form Member enrollment form/application (1page)
Waiver
of Coverage Benefit Refusal/Waiver Form: Dental & Vision (1 Page)
Change
of Status Update your information (i.e. address change; add or delete
a dependent) (1 page)
Employer Forms
Employer
Application Dental & Vision Plans Employer Application; Acknowledgement;
Trust Acceptance & Producers Statement (2 Pages)