OR PacificSource Care Coordination Request Form 2021-2025 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 a copy of the OR PacificSource Care Coordination Request Form from the PacificSource website or your healthcare provider.
2. Fill in patient information at the top, including name, date of birth, and insurance details.
3. Provide the referring provider's information, including name, contact number, and address.
4. Clearly describe the reason for the care coordination request, specifying any medical concerns or needs.
5. Include relevant medical history or notes that support the request for care coordination.
6. List any specific services or resources you are requesting for the patient.
7. Sign and date the form to validate your request.
8. Submit the completed form via the designated method (fax, email, or mail) as indicated on the form.

Who needs OR PacificSource Care Coordination Request Form?

1. Patients with complex medical needs who require additional support and resources.
2. Healthcare providers who need to facilitate a coordinated care plan for their patients.
3. Family members or caregivers seeking to improve care for their loved ones with chronic conditions.

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What is OR PacificSource Care Coordination Request Form?

The OR PacificSource Care Coordination Request Form is a document used by healthcare providers to request care coordination services for patients covered by PacificSource health plans in Oregon.

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

Healthcare providers or facilities that are seeking care coordination services on behalf of their patients 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 need to complete all required fields, including patient information, specific care coordination needs, and any relevant clinical information that supports the request.

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

The purpose of the OR PacificSource Care Coordination Request Form is to facilitate communication and coordination of care for patients, ensuring that they receive appropriate services and support to manage their health.

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 details, the reason for the request, any relevant medical history, and specifics about the services required.