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
Date:
Contact Person:
Phone:
Extension:
Fax:
PATIENT INFORMATION
Last Name:
First Name:
DOB:
Member Number:
PROCEDURE INFORMATION
CPT / HCPCS code and description:
CPT / HCPCS code and description:
CPT / HCPCS code and description:
Notes:
Diagnosis code and description:
Retrospective review?
Dates of Service:
Estimated Length of stay (number of days)
Durable medical equipment:
Cost $
PROVIDER INFORMATION
Ordering provider or surgeon:
Address:
City / State / Zip:
Tax ID:
Phone:
Fax:
Place of service, vendor, or facility:
Address:
City / State / Zip:
Tax ID:
Phone:
Fax:
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
