Get Transition Of Care Services Request Form - Presbyterian Healthcare ... - Phs

Completing the Transition Of Care Services Request Form is an essential step in ensuring a smooth transition of healthcare. This guide will provide you with clear, step-by-step instructions to help you fill out the form accurately and effectively.

Follow the steps to successfully complete the Transition Of Care Services Request Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today’s date in the specified format (MM/DD/YYYY). Following this, fill in the name of the employee or subscriber associated with the insurance plan.
3. Indicate whether the request is for yourself or a dependent. If it is for a dependent, complete the required fields for the dependent.
4. In Section 1, provide information regarding your transition of care needs. Check all applicable boxes regarding your situation, such as needing surgery or follow-up care.
5. Proceed to Section 2 where you will fill in employer information, the member's ID number or SSN, and contact details. Ensure all information is accurate and complete.
6. In Section 3, list the diagnosis codes and descriptions as provided by your medical provider. Include relevant procedure or CPT codes along with a description of services needed.
7. Next, for Section 4, provide the details of the providers rendered transitional services, including their names and provider numbers.
8. If you wish to request case management services, fill in the necessary information in Section 5, detailing any chronic or serious health conditions.
9. Once all sections are completed, review the form for accuracy. After ensuring all information is correct, download and save the form. You can then fax the completed form to the appropriate number provided.

Complete your Transition Of Care Services Request Form online today to ensure your health care needs are met seamlessly.