Follow the steps to fill out the care coordination request form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the employer or group name and the effective date of PacificSource coverage in the designated fields.
3. Enter the employee's last name, first name, address, city, state, zip code, and daytime phone number in the appropriate sections.
4. Input the name of the insured, their date of birth, and any previous insurance coverage details, including the insurance company name, policy number, and coverage dates.
5. Answer the member information section by providing the member's name, relationship to the employee, sex, date of birth, physician name, and physician phone number.
6. Indicate whether the member is currently receiving treatment, scheduled for surgery or hospitalization, receiving chemotherapy or radiation, enrolled in home care or hospice, a candidate for organ transplant, or receiving post-surgery treatment, providing descriptions for each relevant condition.
7. Describe the condition and/or treatment plan for which the member requests assistance in transitioning to PacificSource in the designated text box.
8. Authorize the request or release of information by signing the form and dating it in the specified areas.
9. Once all sections are completed, save your changes, download the form, print it, or share it as needed.

Complete the OR PacificSource Care Coordination Request Form online today to ensure your continuity of care.