Transition Of Care Form
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1
2AETNA BETTER HEALTH®
Transition of care form
Please complete this form and return it in the envelope provided.
Member name _______________________________________Member ID #_________________________
Your name
_________________________Member date of birth ___________________
(if you are not the member)
Address____________________________________________Phone number ( ___ )________________ __
Current Care
1. Have you chosen a new doctor? Yes No
_________________________
( ___ )
If yes, doctor’s name_________________________________________ Phone number
2. Have you scheduled an appointment with your new doctor? Yes No
3. What other doctors do you see?
Doctor’s name_________________________________________________ Phone number ( ___ )________ ___________________
See this doctor for____________________________________________________________________________________________
Doctor’s name_________________________________________________ Phone number ( ___ )________ ___________________
See this doctor for____________________________________________________________________________________________
4. Are you pregnant or have you had a baby in the last 30 days? Yes No
_______________________________
If yes, when are you due? When did you deliver? Date
5. Do you have a doctor for this pregnancy? Yes No
Doctor’s name_________________________________________________ Phone number ( ___ )________ ___________________
6. Are you currently getting home health services? Yes No
7. Are you currently using durable medical equipment
? Yes No
)
(like a wheelchair, oxygen or breathing machine
8. Are you scheduled for or receiving any of the following:
Elective surgery
Physical, speech or occupational therapy
Rehabilitation therapy
Cancer treatment
Substance abuse treatment
Mental health treatment
______________________________________
Dialysis
Other ____
Medications
1. Are you currently taking medications or using any injectable medication(s), other than insulin? Yes No
2. Do you think you will have a problem getting any prescription filled over the next 90 days? Yes No
Confidentiality notice: this document contains confidential information intended for a specific purpose and is protected by law.
CONTINUED ON REVERSE
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Parent category: Business