Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Continuity Of Care Form - Anthem and open it in the online editor.
2. Begin by providing general information about yourself. Fill in the subscriber’s name, Anthem Blue Cross ID number, employer name, and the date you became active with Anthem Blue Cross.
3. Next, include the patient’s name, their relationship to the subscriber, date of birth, and any allergies.
4. Indicate your preferred phone number and secondary contact number. Specify if it is a home, work, or cell number.
5. State the name of the terminating insurance plan, and circle the type of that plan. Then, specify your new Anthem Blue Cross plan type.
6. Answer whether you are a new enrollee to Anthem Blue Cross. Provide the names of the PMG/IPA associated with both the terminating plan and the new Anthem Blue Cross plan.
7. If applicable, detail the diagnosis, including relevant medical history. If you have upcoming appointments with specialists, provide their names, types, phone numbers, appointment dates, and reasons for visits.
8. Indicate if you are currently receiving any ongoing services. List the services along with the associated medical or behavioral health providers.
9. Provide information about any scheduled hospitalizations, surgeries, or procedures, including dates and the names of the physicians performing them.
10. Disclose if you have been admitted to the hospital or visited the emergency room in the past six months, including the reason and dates of services.
11. Complete any other needs section with relevant information.
12. Finally, sign the authorization section, giving permission for the provider to share necessary medical records with Anthem Blue Cross, and specify the preferred contact method for confidential information.
13. After completing all fields, save your changes and prepare to download, print, or share the completed form as needed.

Start filling out your Continuity Of Care Form - Anthem online today to ensure seamless health care!