Get the free Continuity of Care Form - Memorial Hermann Health Plan

Continuity of Care Form Continuity of care will be issued under special circumstances to allow members to continue treatment with a nonplan provider(s) for a period of time following the date of enrollment.

How to fill out continuity of care form

How to fill out continuity of care form

1. Obtain the continuity of care form from the appropriate medical provider or facility.
2. Fill in your personal information such as name, date of birth, address, and contact information.
3. Include information about your current healthcare provider and any specialists you are seeing.
4. Provide details about your medical history, including past illnesses, surgeries, and medications.
5. Specify any ongoing medical conditions or allergies that healthcare providers should be aware of.
6. Sign and date the form to confirm that the information provided is accurate.

Who needs continuity of care form?

1. Patients who are transitioning to a new healthcare provider.
2. Patients who are seeking a second opinion from a different healthcare provider.
3. Patients who are receiving care from multiple healthcare providers and need to ensure continuity of treatment.

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What is continuity of care form?

The continuity of care form is a document used to ensure that a patient's care and treatment are maintained consistently when there is a change in healthcare provider.

Who is required to file continuity of care form?

Healthcare providers and facilities are required to file the continuity of care form when transferring a patient's care to another provider.

How to fill out continuity of care form?

The continuity of care form should be filled out with relevant patient information, current treatment plan, and any other pertinent details regarding the patient's care.

What is the purpose of continuity of care form?

The purpose of continuity of care form is to ensure continuity and quality of care for the patient during the transition between healthcare providers.

What information must be reported on continuity of care form?

The continuity of care form must include the patient's medical history, current medications, treatment plan, and any other relevant information for the new healthcare provider.