Form Mkt220 - Continuity Of Care Request Form - Bluecross Blueshield Of Alabama printable pdf download

CONTINUITY OF CARE

REQUEST FORM

An Independent Licensee of the Blue Cross and Blue Shield Association

Continuity of Care is a service offered to our members receiving medical care by a physician, hospital or other provider whose contractual relationship

with Blue Cross and Blue Shield of Alabama is terminating or has terminated. This service may allow a specified transition period to provide consistent

quality medical care while a new provider is identified. Continuity of Care may be offered under certain, limited conditions.

Benefit levels provided as part of Continuity of Care are for the specific illness or condition(s) listed and cannot be applied to any other illnesses or condition(s).

You must complete a Continuity of Care Request form for each condition and return no later than 30 days after the healthcare provider’s termination date.

Patient Information

Date of

Patient’s

Middle

Last Name

First Name

Initial

Birth:

Relationship

Contract Holder’s

Middle

Last Name

First Name (if applicable)

Initial

to Patient:

Contract Number

Group

Sex of Patient:

Male

Female

(include prefix)

Number

Work Telephone

Home or Cell

Telephone

Address

City

State

Zip

Physician Information (to be filled out by Physician)

Individual NPI

Physician

Physician’s

Name

Specialty

(National Provider Identifier)

Address

City

State

Zip

Physician’s

Telephone

1. Is the patient pregnant?................................................................................................................................................................................................

Yes

• If yes, when is the due date? _______________(mm/dd/yyyy)

2. Has the patient undergone an organ or bone transplant in the past six months?...............................................................................................................

Yes

• If yes, when did the transplant occur? _______________(mm/dd/yyyy)

3. Medical condition for continuity of care consideration:

__________________________________________________________________________________________________________________________

4. Diagnosis (also give ICD-9 code):

5. Member’s Condition and Current Treatment Plan – Please include the anticipated length of time the continuity of care services are requested and any narratives or copies

of medical records that will facilitate the evaluation process for your patient:

__________________________________________________________________________________________________________________________

I support this member’s request for continuity of care. As the physician, I understand that should Blue Cross approve this continuity of care service request, Blue Cross and

I and/or any terminated facility will need to enter into a continuity of care agreement.

Physician Signature

Date (mm/dd/yyyy)

__________________________________________________________________________________________________________________________

Hospital Information

Hospital

Hospital Name

Telephone

(where patient’s doctor practices)

Address

City

State

Zip

I certify this information is complete and correct to the best of my knowledge.

Each case will be considered individually, and approval is only for treatment of the specific health condition. Benefits are subject to the contractual limitations and exclusions

set forth in the member’s contract/certificate. Any approval of continuity of care does not extend the contractual benefits in any way except to provide in-network level of

benefits for a non-network provider for a temporary time period.

Printed Name of Patient,

Signature of Patient,

Date

Parent or Guardian

(mm/dd/yyyy)

__________________________________________________________________________________________________________________________

Mail to: Blue Cross and Blue Shield of Alabama • P.O. Box 2684 • Birmingham, AL 35283-2684 or Fax: 205-402-5727

MKT220-1610