Please provide all of the requested information by typing in the boxes on screen.
When finished, click the Print Form button.
Have your practice's office manager or provider sign your request form where indicated.
Fax your signed request form to the PacificSource Provider Network Department at (541)
225-3643.
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Watch for your temporary PIN and login instructions to arrive by U.S. mail within a few days.
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Please note that
PIN requests must be typed to avoid processing delays.
Please provide the name, e-mail address, and provider or practice tax ID number of each
person who should have access to PacificSource InTouch. Please do not enter a Social Security number in place of a tax ID number. The
e-mail address will become the InTouch User ID. For privacy, users should not share user names or passwords. If any staff members do not have their own e-mail address,
please contact our Provider Network Department at (541) 684-5580 or toll-free at (800) 624-6052, ext. 2580 for assistance.
Authorization:
To be completed by the provider or his/her designated
representative.
I understand that PacificSource InTouch is a secure Web site
that allows access to confidential medical and personal information.
I also understand that by signing below, I authorize the
employees listed above to access that information on behalf
of my practice. PacificSource will then issue unique PINs
for each authorized employee, and those PINs should not be
shared with anyone else without my express permission.
_____________________________________
_________________
Authorized Signature
Date
Click the Print Form button below, sign your form, and
return it via fax to (541) 225-3643.
Please note
that PIN requests must be typed to avoid processing delays.
Return to
PacificSource Web site
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