Get Care Coordination Request Form

Completing the Care Coordination Request Form online is a straightforward process that enables users to effectively communicate their care needs to PacificSource. This guide will provide you with a step-by-step approach to ensure each section is filled out accurately.

Follow the steps to complete the form efficiently.

1. Press the ‘Get Form’ button to access the Care Coordination Request Form and open it for editing.
2. Begin by filling out the enrollment information section, which includes providing details such as employer or group name, effective date of PacificSource coverage, and the employee's personal details including last name, first name, and middle initial.
3. Complete the mailing address section, ensuring you include the city, state, and zip code accurately to facilitate contact.
4. In the prior insurance coverage information, supply the name of the insured, insurance company name, policy number, and coverage dates. Indicate whether the coverage will remain in effect during your time with PacificSource.
5. Fill in the member information section. Include the name of the member, their relationship to the employee, sex assigned at birth, and gender identity, along with the member's date of birth and physician's phone number.
6. Answer any questions regarding the member's current medical treatment, such as whether they are receiving treatment for any conditions, scheduled for surgery, or enrolled in home care. Provide detailed descriptions where necessary.
7. Document any prescription medications the member regularly takes, including the prescribing doctor's details. Specify if the medications are brand-name or generic.
8. Describe the condition or treatment plan for which the member is requesting assistance in transitioning to PacificSource.
9. Complete the authorization section, signing and dating the document to allow PacificSource to disclose necessary health information.
10. After reviewing all information for accuracy, save your changes, then proceed to download, print, or share the form as needed.

Get started on completing your Care Coordination Request Form online today.