For Providers: Forms

PacificSource Forms

You're welcome to download and print current versions of the following PacificSource forms - just click on the form you need. The forms are in Adobe Acrobat PDF format.

Accident Report
Behavioral Health Treatment Plan Review Request

Chemical Dependency Treatment Plan Review Request

Corrected Claim Form

Credentialing Forms

Disabled Dependent Certification

InTouch for Providers Registration

Preauthorization Request - Medical

Preauthorization Request - Dental

Prescription Drug Preauthorization Request

Referral Authorization Request

CPAP Rent to Purchase Form

HCFA 1500 Claim Form

HCFA UB04 Claim Form

W-9 (IRS) - Request for Taxpayer ID Number

Informational Fliers

Online Tools for Providers at PacificSource.com

Electronic Claims Submission

Expectations Prenatal Program

Provider Directory Instructions

Specialty Pharmacy Services

Credentialing Forms

Oregon:

Oregon Credentialing Application

Organizational Credentialing Application

Recredentialing Application

Idaho:

Instructions

Attestation & Acknowledgement (required)

Idaho Credentialing Application

Organizational Credentialing Application

Recredentialing Application

Washington:

Instructions

Attestation & Acknowledgement (required)

Washington Credentialing Application

Organizational Credentialing Application

Recredentialing Application