Get Transition Of Care/ Continuation Of Care Request Form - Health Net

Filling out the Transition Of Care/ Continuation Of Care Request Form - Health Net online can streamline your healthcare transitions. This guide provides clear instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Carefully enter the patient's name in the fields labeled 'Patient’s name (last, first, MI)'. Ensure you provide the full name for identification purposes.
3. Input the patient's phone number in the designated area, including the area code. It is also helpful to include the best time to call.
4. Fill in the patient's date of birth and member ID number. Check that the gender is accurately marked as 'M' for male or 'F' for female.
5. List the patient's address in the appropriate fields, including city, state, and ZIP code.
6. Document the health plan's primary care physician and the corresponding medical group associated with the patient.
7. Identify the current attending physician or provider by providing their name and address. Include the next scheduled appointment date and the reason for this appointment.
8. Indicate whether the patient has a Health Net participating physician and if they are pregnant. If applicable, provide the expected date of delivery.
9. Detail any additional services required, such as dialysis or home health care, indicating if these services are needed.
10. Write a brief explanation of the assistance required for current medical care, clearly stating the type of services being requested.
11. Complete the section regarding any other special needs or comments that may provide additional context to your request.
12. Ensure the form is fully signed, either by the member or the Health Net Member Service Representative who is submitting the request.
13. Once completed, save changes to the form. You can then download, print, or share the completed form as needed for submission.

Take the next step in your healthcare journey by completing the Transition Of Care/ Continuation Of Care Request Form online today.