Get First Care Health Plan Continuity Of Care/transition Of Care Request Form 2019-2025

Filling out the First Care Health Plan Continuity Of Care/Transition Of Care Request Form online is a straightforward process designed to ensure you receive the necessary medical and behavioral health coverage. This guide will walk you through each section of the form to help you complete it accurately and efficiently.

Follow the steps to complete your form accurately.

1. Use the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Begin with general information; fill in the details about the employer, policy number, and date of enrollment in FirstCare. Ensure all fields are completed without leaving blanks. Use 'N/A' for any non-applicable information.
3. Input the employee's name and their social security number or alternate ID, along with their work and home phone numbers, email address, and home address.
4. Enter the patient's information, including their name, social security number or alternate ID, birth date, and their relationship to the employee.
5. Respond to the eligibility questions regarding the patient's current medical conditions or treatments. These include inquiries about pregnancy status, ongoing treatments, surgical procedures, and other relevant health conditions.
6. If applicable, provide details of the health care professional the patient is currently seeing. Include their name, practice name, contact information, specialty, and the details of previous treatments received.
7. Answer the question regarding whether the patient is expected to be hospitalized during the first 90 days of coverage.
8. List any other continuing care needs that may qualify for coverage. Separate forms may be needed for additional care conditions.
9. Complete the authorization section, granting permission to the health care provider to share necessary information with FirstCare. Indicate how you wish to receive confidential information.
10. Sign and date the form to validate your request. Ensure that all sections are complete before submission.
11. Once completed, save your changes, and you may choose to print, download, or share the form as needed.

Begin filling out your First Care Health Plan Continuity Of Care/Transition Of Care Request Form online today to ensure uninterrupted care.