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MULTNOMAH COUNTY administered by PACIFICSOURCE ADMINISTRATORS MERP DCAP ENROLLMENT FORM 2017 Calendar Year January 1 2017 through December 31 2017 Personnel Number Date of Birth Last Name First Initial Street Address City State Home Phone Check One Zip Code Work Phone New Employee Rehire Extension Event Date Return from Leave Specify the total amount you want to contribute by payroll deduction in 2017. You do not need to turn in a form if you do not want to enroll in either MERP or DCAP....
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What is pacificsource administrators?
PacificSource Administrators is a third party administrator that provides administrative services for self-funded health plans.
Who is required to file pacificsource administrators?
Employers who offer self-funded health plans and utilize PacificSource Administrators for administrative services are required to file.
How to fill out pacificsource administrators?
To fill out PacificSource Administrators, employers need to submit the necessary enrollment and claims data to the administrator.
What is the purpose of pacificsource administrators?
The purpose of PacificSource Administrators is to manage the day-to-day operations of self-funded health plans on behalf of employers.
What information must be reported on pacificsource administrators?
Employers must report enrollment data, claims information, and other relevant details about the health plan to PacificSource Administrators.
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