OR PacificSource Care Coordination Request Form 2021 free printable template

Care Coordination Request Form Welcome to PacificSource! If you are a new member with an active medical or drug treatment plan, you may have questions about continued treatment through your PacificSource

How to fill out OR PacificSource Care Coordination Request Form

How to fill out OR PacificSource Care Coordination Request Form

1. Obtain the OR PacificSource Care Coordination Request Form from the PacificSource website or your healthcare provider.
2. Fill in the patient’s personal information, including name, date of birth, and insurance identification number.
3. Provide detailed information regarding the reason for the request, including any relevant medical history.
4. Indicate the type of care coordination services needed, such as case management or home health support.
5. Include the healthcare provider's information who is making the request, including name and contact details.
6. Check for any supporting documents you need to attach to the request form.
7. Review the completed form for accuracy and completeness.
8. Submit the form as per the instructions provided on the form, either online or by mail.

Who needs OR PacificSource Care Coordination Request Form?

1. Patients who require assistance in coordinating their healthcare services.
2. Healthcare providers who are referring patients for care coordination.
3. Family members or caregivers of patients who are seeking additional support for care management.

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What is OR PacificSource Care Coordination Request Form?

The OR PacificSource Care Coordination Request Form is a document used to initiate and facilitate care coordination services for patients covered by PacificSource Health Plans in Oregon.

Who is required to file OR PacificSource Care Coordination Request Form?

Health care providers, including physicians and specialists, who are coordinating care for patients under PacificSource Health Plans are required to file the OR PacificSource Care Coordination Request Form.

How to fill out OR PacificSource Care Coordination Request Form?

To fill out the OR PacificSource Care Coordination Request Form, providers should complete all required fields, including patient information, diagnosis, services requested, and any relevant medical history. Additionally, providers should ensure that all sections of the form are reviewed for accuracy before submission.

What is the purpose of OR PacificSource Care Coordination Request Form?

The purpose of the OR PacificSource Care Coordination Request Form is to ensure that patients receive appropriate care management and services by communicating patient needs and coordinating efforts among health care providers.

What information must be reported on OR PacificSource Care Coordination Request Form?

The information that must be reported on the OR PacificSource Care Coordination Request Form includes patient demographics, insurance information, specific medical conditions, requested services, and provider details.