Get Continuation Of Care Request Form (standard) - Amerihealth.com

This guide provides step-by-step instructions for effectively completing the Continuation Of Care Request Form (Standard) online. By following these clear directions, users can ensure that all necessary information is accurately captured to facilitate the continuation of care.

Follow the steps to successfully complete the Continuation Of Care Request Form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Begin filling out the member information section. Enter the Member ID number, effective date of coverage, subscriber name, group number, and group name in their respective fields.
3. In the patient information section, provide the patient's name, date of birth, street address, city, state, ZIP code, and home phone number.
4. Next, navigate to the provider information section. Fill in the doctor's name, street address, city, state, specialty, office phone number, and ZIP code.
5. Specify the condition being treated and indicate how long the doctor has been treating the patient for this condition by filling in the years and months.
6. Enter how long the treatment is expected to continue by providing the estimated number of visits, years, and months.
7. Add any additional comments that may be relevant to the request in the designated comments section.
8. Once you have completed all sections of the form, save your changes. You can then download, print, or share the form as needed.

Complete your Continuation Of Care Request Form online today to ensure uninterrupted health services.