Get the free Continuity of Care Request Form - Valley Health Plan
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Continuity of Care Sequestrate:Member phone number:Member Name:Member ID #:Member contact address:
Request received by (mark one):PhoneEmailLetterFaxName of Medical Provider:
Provider Address:
Provider
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How to fill out continuity of care request
How to fill out continuity of care request
01
Contact your current healthcare provider and ask for a continuity of care request form.
02
Fill out your personal information including your name, date of birth, and contact information.
03
Fill out information about your current healthcare provider, including their name, address, and contact information.
04
Include the reason for the continuity of care request, such as moving to a new area or changing insurance plans.
05
Sign and date the form before submitting it back to your healthcare provider.
Who needs continuity of care request?
01
Individuals who are changing healthcare providers.
02
Individuals who are moving to a new location and need to transfer their medical records.
03
Individuals who are changing insurance plans and want to continue with the same healthcare provider.
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What is continuity of care request?
It is a request made by a patient to continue receiving care from a specific healthcare provider even if they are not in-network.
Who is required to file continuity of care request?
Patients who wish to continue receiving care from an out-of-network provider.
How to fill out continuity of care request?
Patients can typically fill out a form provided by their insurance company or healthcare provider, providing information about their current treatment and the need for continued care.
What is the purpose of continuity of care request?
The purpose is to ensure that patients can continue treatment with a specific provider even if they are not in-network, often due to special circumstances such as ongoing treatment or a unique relationship with the provider.
What information must be reported on continuity of care request?
Patients may need to provide details about their current treatment plan, medical history, the provider they wish to continue seeing, and the reasons for needing out-of-network care.
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