If you are a new member currently involved in an active medical or drug treatment plan, you may have 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your Employer/Group Name and the effective date of your PacificSource coverage. Ensure all dates are formatted correctly.
3. Provide your personal information, including your last name, first name, address, city, state, zip code, and daytime phone number.
4. In the CURRENT AND PRIOR INSURANCE COVERAGE INFORMATION section, enter the insurance company name and policy number. Indicate whether coverage will remain in effect while covered by PacificSource.
5. Complete the MEMBER INFORMATION section by entering the member's name, relationship to employee, sex, date of birth, physician's name, and phone number.
6. Answer the questions regarding current treatments and surgeries. Provide detailed descriptions where necessary to ensure clarity.
7. In the AUTHORIZATION TO REQUEST/RELEASE INFORMATION section, sign and date the form to authorize PacificSource Health Plans to access necessary health information.

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