Requests may be submitted
online through InTouch
PacificSource.com/aboutproviderintouch or fax this form to: 541.225.3625
A determination notice will be mailed and/or faxed to the requesting provider, facility, and patient.
- PacificSource responds to preauthorization requests within two (2) working days.
- Requests received after 3:00 p.m. are processed the next work day.
- Incomplete information will delay the preauthorization process.
- Please include pertinent chart notes to expedite this request.
REQUESTING PROVIDER CONTACT INFORMATION
Health Services Department
110 International Way, Springfield OR 97447 ● PO Box 7068, Springfield OR 97475-0068
541.684.5584 ● Toll-free 888.691.8209 ● Confidential Fax 541.225.3625
Preauthorization Request Form (OR) 0915