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
MES 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)