Get the free Continuation of Care Request Form. Continuation of Care Request Form

Rev. 12/2019Continuation of Care Request Form Date:Form completed by:Phone #:REASON FOR REQUEST o Member newly enrolled with AmeriHealth Pennsylvania o Provider no longer participates with the AmeriHealth

How to fill out continuation of care request

How to fill out continuation of care request

1. To fill out a continuation of care request, follow these steps:
2. Obtain a continuation of care request form from your healthcare provider.
3. Fill in your personal information, such as your full name, date of birth, and contact details.
4. Provide your current healthcare provider's name and contact information.
5. Include the reason for the continuation of care request, specifying why you need ongoing treatment or care.
6. Attach any supporting documents, such as medical records or test results, to validate your request.
7. Sign and date the form to acknowledge your consent for the release of your medical information.
8. Submit the completed form to your healthcare provider or the designated department.
9. Follow up with your healthcare provider to ensure that your request has been processed.
10. Keep a copy of the filled-out form and any supporting documents for your records.

Who needs continuation of care request?

1. A continuation of care request is needed by individuals who require ongoing treatment or care from a new healthcare provider. This may include patients who are transitioning between hospitals, clinics, or healthcare systems, or those who are moving to a new location and need to transfer their medical care. It ensures the continuity of their healthcare by providing the necessary information to their new provider and facilitating the transfer of their medical records.

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What is continuation of care request?

A continuation of care request is a formal request to continue receiving health care services from a specific provider or facility.

Who is required to file continuation of care request?

Patients who wish to continue receiving care from a specific provider or facility are required to file a continuation of care request.

How to fill out continuation of care request?

To fill out a continuation of care request, patients need to provide their personal information, details of their current provider or facility, reasons for requesting continuation of care, and any supporting documents.

What is the purpose of continuation of care request?

The purpose of a continuation of care request is to ensure seamless transition and continuity of care for the patient from one provider or facility to another.

What information must be reported on continuation of care request?

The information that must be reported on a continuation of care request includes patient's personal details, current provider or facility information, reasons for continuation of care, and any necessary supporting documents.