CARE COORDINATION REQUEST FORM OREGON 2026

1. Click ‘Get Form’ to open the CARE COORDINATION REQUEST FORM OREGON 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. Next, provide Prior Insurance Coverage Information. Fill in the name of the insured, insurance company name and policy number along with coverage dates. Indicate whether this coverage will remain effective while covered by PacificSource.
4. In the Member Information section, enter the member's name and relationship to the employee. Complete gender-related fields and physician information as required.
5. Answer all relevant questions regarding current treatments or conditions. Provide details where necessary for any 'Yes' responses.
6. List any prescription medications regularly taken by the member along with prescribing doctor information.
7. Finally, complete the Authorization to Request/Release Information section by signing and dating the form before submission.

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