Get Or Pacificsource Care Coordination Request Form 2019

Filling out the OR PacificSource Care Coordination Request Form online can be a straightforward process when you follow the right steps. This guide will provide you with clear instructions on how to complete each section of the form effectively, ensuring you submit your request for care coordination seamlessly.

Follow the steps to successfully complete the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the enrollment information section. Enter the employer or group name, the effective date of coverage, the employee's last name, first name, and middle initial.
3. Provide the mailing address, city, state, and zip code of the employee, along with their date of birth, daytime phone number, and email address.
4. Next, move to the current and prior insurance coverage information. List the name of the insured, the insurance company name, policy number, and coverage dates. Indicate whether the coverage will remain in effect while covered by PacificSource.
5. In the member information section, include the name of the member, their sex, and relationship to the employee. Fill in the member's date of birth and the physician's name, along with the physician's phone number.
6. Answer the questions regarding the member’s current health status, indicating whether they are receiving treatment for any conditions, scheduled for surgery, or involved in any other relevant medical situations.
7. List any prescribed medications the member regularly takes. Include the medication name, the name of the prescribing doctor, and their phone number.
8. Describe the condition and/or treatment plan for which the member requests assistance in transitioning to PacificSource.
9. Complete the authorization to request/release information section by signing and dating the form to give permission for PacificSource to request and disclose health information.
10. After filling out all sections, ensure to review your answers for accuracy, then save your changes. You can download, print, or share the completed form as needed.

Start completing your forms online today for a smoother care coordination experience.