Get Continuity Of Care Form - Florida

The Continuity Of Care Form - Florida is designed to help individuals seeking continued medical care from non-contracted providers. This guide provides detailed instructions on how to fill out the form online, ensuring users understand each section and its requirements.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to obtain the Continuity Of Care Form and open it in your browser.
2. Begin by completing Section 1, which asks about your current medical situation. Answer whether you are pregnant or currently receiving treatment for a specific condition. Provide a brief description of your condition and treatment if applicable.
3. If you answered 'YES' to any question in Section 1, proceed to complete Section 2. Fill in your personal details including your name, identification number, address, contact numbers, employer information, patient details, and their date of birth. Indicate your relationship to the patient and specify if you are covered by Medicare or Medicaid.
4. Sign the authorization to release medical records, allowing healthcare providers to share relevant information with UnitedHealthcare for the eligibility determination process. Ensure patient or guardian signature is provided if the applicant is a minor.
5. Next, have the treating physician complete Section 3, which requires them to provide their name, contact number, address, date of last visit, and the next scheduled appointment. They should also include the diagnosis, expected length of treatment, and for maternity cases, the expected date of delivery and the planned hospital.
6. Once all sections have been completed, review the form for accuracy. Then, mail the completed application along with any necessary medical records to the address listed at the top of the application within 30 days of receipt of notification to ensure eligibility for care.

Complete your documents online today for a seamless process.