Directory information, not recipient confirmation. Fax numbers can change and differ by department, location, form, or plan. Confirm this destination directly with PacificSource Health Plans before sending sensitive documents. FaxFlow is not affiliated with this organization.
PacificSource Health Plans fax number
(541) 225-3628
Grievance Review
Used for: Grievances and Appeals submissions; designation of Authorized Representative for pursuing benefit determinations; used to file grievances/appeals and authorize another person to act on your behalf.
Fax destination details
- Department
- Grievance Review
- Purpose
- Grievances and Appeals submissions; designation of Authorized Representative for pursuing benefit determinations; used to file grievances/appeals and authorize another person to act on your behalf.
- Form
- Designation of Authorized Representative Form — Designation of Authorized Representative Form
- Address
- PO Box 7068, Springfield, OR 97475-0068
- Voice phone
- 888-977-9299
- Website
- Visit organization website
Before you send
- Confirm that this exact department handles your document or request.
- Check the organization website or call its main line for the current fax number.
- Include a cover sheet and any case, member, claim, or form reference required.
- Keep the delivery confirmation with your submission records.
Fill member information, designate the authorized representative, sign and date, then mail to PacificSource Health Plans Attn: Grievance Review PO Box 7068 Springfield, OR 97475-0068 or fax to 541-225-3628. For questions call 888-977-9299 (TTY: 711).
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