Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the enrollment information. Include the employer or group name, the effective date of your PacificSource coverage, and the employee's last name, first name, middle initial, mailing address, city, state, zip code, date of birth, daytime phone number, and email address.
3. Provide prior insurance coverage information. Fill in the name of the insured, insurance company name, policy number, and coverage dates. Indicate if the coverage will remain effective while covered by PacificSource.
4. Complete the member information section. Enter the member's name, relationship to the employee, sex assigned at birth, gender identity (optional), physician's name, date of birth, and physician's phone number. Answer the questions regarding current treatment, surgeries, cancer therapy, home care, organ transplants, disease management programs, and pregnancy.
5. List any prescription medications the member regularly takes, including the name and phone number of the prescribing doctor for each medication.
6. Briefly describe the condition and/or treatment plan for which assistance is being requested to transition to PacificSource.
7. In the authorization to request/release information section, read the statement carefully. Sign and date the form to authorize PacificSource Health Plans to manage your health information.
8. Once all sections are completed, make sure to save any changes made to the form. You can then download, print, or share the form as needed.

Complete your OR PacificSource Care Coordination Request Form online today to ensure your continued care.