Get Provider Nomination Form Pacificsource Network

Filling out the Provider Nomination Form for the PacificSource Network is essential for nominating a healthcare provider to participate in your health plan. This guide provides clear, step-by-step instructions to ensure the process is simple and efficient.

Follow the steps to complete the Provider Nomination Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section, including your name, address, and employer. Make sure all information is accurate to avoid any delays.
3. Select the provider network from your PacificSource member ID card: PSN, SmartHealth, or Prime. Indicate your choice clearly.
4. Once you have completed the patient information, provide the healthcare provider with the form. You may either send it via mail or present it during your next visit.
5. If your provider expresses interest in joining the network, they will need to fill out the provider section of the form, including their name, office address, specialties, and Tax ID.
6. After your provider completes their section, ensure the form is submitted to PacificSource Health Plans via mail, fax, or email as indicated on the form.
7. Please allow four to six weeks for the nomination to be reviewed. If you have any questions during this period, contact your provider directly.
8. Once the process is complete, you can save changes, download, print, or share the form as needed.

Start your nomination process online today by filling out the Provider Nomination Form.