Forms & Brochures
We have provided Adobe Acrobat files for all the forms and applications. You will need to download the Adobe Acrobat Reader to view these files.
Program Information
PairedChoice by PacAdvantage
July 2006
Employer Handbook
Optional Benefits Summary
Member Benefits Summary (Kaiser Permanente & Health Net)
Member Benefits Summary (Kaiser Permanente & Health Net - Spanish)
Member Benefits Summary (Kaiser Permanente & Blue Shield)
Member Benefits Summary (Kaiser Permanente & Blue Shield - Spanish)
May 2006
Member Benefits Summary (Kaiser Permanente & Health Net)
January 2006
Employer Handbook
Optional Benefits Summary
Optional Benefits Summary (Spanish)
Member Benefits Summary (Kaiser Permanente & Health Net)
Member Benefits Summary (Kaiser Permanente & Health Net - Spanish)
Member Benefits Summary (Kaiser Permanente & Blue Shield)
Member Benefits Summary (Kaiser Permanente & Blue Shield - Spanish)
Member Benefits Summary (Kaiser Permanente, Aetna & Regional Carriers)
July 2005
Employer Handbook
Optional Benefits Summary
Member Benefits Summary (Kaiser Permanente & Health Net)
Member Benefits Summary (Kaiser Permanente & Blue Shield)
Member Benefits Summary (Kaiser Permanente, Aetna & Regional Carriers)
PacAdvantage Pool
July 2006
Employer Handbook
Member Benefits Summary
Member Benefits Summary (Spanish)
Optional Benefits Summary
January 2006
Employer Handbook
Member Benefits Summary
Member Benefits Summary (Spanish)
Optional Benefits Summary
Optional Benefits Summary (Spanish)
July 2005
Employer Handbook
Employer Benefits Summary
Optional Benefits Summary
Forms & Brochures
Employer
Pool Employer Enrollment Form
Pool Employer Open Enrollment Form
PairedChoice Open Enrollment Form
PairedChoice Employer Application
PairedChoice & Pool Electronic Funds Transfer Form
PairedChoice & Pool Certification of Corporate Wage Earner/Self-Employed Income
PairedChoice & Pool Employer Health Questionnaire
PairedChoice & Pool Premium Only Plan Application
Employer Census Form
Group Requalification Letter
Members
PairedChoice & Pool Employee Summary of Rules & Procedures
PairedChoice Employee Enrollment Application
PairedChoice Employee Enrollment Application in Spanish (Solicitud De Inscripción Del Empleado)
PairedChoice Employee/Member Open Enrollment Change Form
Pool Employee Enrollment Application
Pool Employee/Member Open Enrollment Change Form
PacAdvantage Dependent Disability form
Pool Employee Enrollment in Spanish (Solicitud De Inscripción Del Empleado)
PairedChoice & Pool Member Termination Form
PairedChoice & Pool Employee Health Questionnaire
PairedChoice & Pool Employee Health Questionnaire in Spanish (Cuestionario Sobre La Salud Del Empleado)
PairedChoice & Pool Refusal of Coverage Form
PairedChoice & Pool Refusal of Coverage Form in Spanish
COBRA
Federal COBRA & PacAdvantage
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