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UNICARE STATE INDEMNITY PLANCONTINUITY/TRANSITION OF CARE
REQUEST Former Unifier plan membersForm completion incomplete and submit this form if you are currently receiving ongoing care or if you have
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How to fill out continuitytransition of care request
How to fill out continuitytransition of care request
01
Obtain the continuity/transition of care request form.
02
Fill out the patient's demographic information including name, date of birth, and contact information.
03
Provide details about the transferring or receiving healthcare provider, including name, address, and contact information.
04
Include information about the patient's medical history, current medications, allergies, and relevant treatment plans.
05
Sign and date the form, ensuring all necessary information is accurately provided.
Who needs continuitytransition of care request?
01
Healthcare providers who are either transferring or receiving a patient for continued or transitional care.
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What is continuity/transition of care request?
It is a request for the continued or transition of care from one healthcare provider to another.
Who is required to file continuity/transition of care request?
The healthcare provider or the patient may be required to file the request, depending on the situation.
How to fill out continuity/transition of care request?
The request can be filled out by providing relevant medical information, contact details, and reason for the request.
What is the purpose of continuity/transition of care request?
The purpose of the request is to ensure seamless continuity of care for the patient when transitioning between healthcare providers.
What information must be reported on continuity/transition of care request?
Information such as medical history, current medications, treatment plans, and contact information should be included in the request.
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