PDF care coordination request form oregon - PacificSource 2026

1. Click ‘Get Form’ to open the PDF care coordination request form in the editor.
2. Begin by filling out the Enrollment Information section. Enter your Employer/Group Name, effective date of coverage, and your personal details including last name, first name, middle initial, mailing address, city, state, zip code, date of birth, daytime phone number, and email address.
3. Proceed to the Current and Prior Insurance Coverage Information section. Provide the name of the insured, insurance company name, policy number, coverage dates, and indicate if coverage will remain in effect while covered by PacificSource.
4. In the Member Information section, enter the member's name, sex, relationship to employee, date of birth, physician details and answer questions regarding current treatments or conditions.
5. Complete the Authorization to Request/Release Information section by signing and dating where indicated. This authorizes PacificSource to manage your healthcare benefits effectively.

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