Care Coordination Request Form: Fill out & sign online

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Click ‘Get Form’ to open the Care Coordination Request Form in the editor.
Begin by filling out the Enrollment Information section. Enter your Employer/Group Name, effective date of coverage, and personal details such as your last name, first name, mailing address, date of birth, daytime phone number, and email address.
Proceed to the Prior Insurance Coverage Information section. Provide details about any previous insurance coverage including the name of the insured, insurance company name, policy number, and coverage dates.
In the Member Information section, enter the member's name and relationship to you. Fill in their sex assigned at birth and gender identity if applicable. Include physician details and any current treatment information.
Complete the Authorization to Request/Release Information section by signing and dating where indicated. This allows PacificSource to manage your healthcare benefits effectively.

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