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Get Or Pacificsource Care Coordination Request Form 2016-2024

Ment under PacificSource coverage. We understand your concern and will contact you (or your designee) to discuss your ongoing care needs. Please complete all applicable sections below, and return the form as soon as possible to: PacificSource Health Plans ATTN: Health Services Dept. PO Box 7068 Springfield, OR 97475-0068 Fax (541) 225-3625 If you have questions, please call Health Services at (541) 684-5584, or toll-free at (888) 691-8209 Employer/Group Name Date PacificSource coverage will be.

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