Student’s Name: ________________________________________Student’s Anthem Blue Cross ID #:
Student’s Campus: ______________________________________ Date Active with Anthem Blue Cross:
Patient’s Name: ________________________________________ Relationship to Student:
Date of Birth: __________________________________________ Allergies:
Preferred Phone #: _____________________ Home Work Cell Secondary Phone#:_____________________ Home Work Cell
Name of Terminating Insurance Plan: _______________________ Circle Type of Terminating Plan: HMO PPO EPO CDHP OTHER
New Anthem Blue Cross Plan: HMO PPO EPO CDHP OTHER Are You a New Enrollee to Anthem Blue Cross: Yes No
Name of PMG/IPA with Terminating Plan: ____________________ Name of New Anthem Blue Cross PMG/IPA: ________________
For Network
Disruption(PMG, IPA, PPO Provider, or Hospital has terminated from the
Anthem BlueCross Participating Provider Network) please provide the name
of theterminating Hospital or
Provider: _____________________________________________
Diagnosis (include pertinent history and physical findings): __________________________________________________________
_________________________________________________________________________________________________________
1. Do you have an upcoming appointment to see a specialist? Yes No
If yes, please provide the applicable information below.
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Specialist Type
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Provider Name
(last, first)
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Provider
Phone Number
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Date of Office Visit
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Reason
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Heart Specialist
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Lung Specialist
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Blood or Cancer Specialist
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Neurologist
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Infectious Disease Specialist
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Kidney Specialist
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Behavioral Health Specialist
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Orthopedic Specialist
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Obstetrician for pregnancy
Due Date:
Hospital for delivery:
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Other: Please be specific
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2. Are you currently receiving any of the following services? Yes No
If yes, please provide the applicable information below.
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Services
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Facility or Company, Medical or Behavioral Health Provider
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Clinical Laboratory
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Oxygen
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IV Medication/Chemotherapy
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Physical Therapy
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Radiation Therapy
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Home Therapy
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Rehab Treatment
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Organ or Stem Cell/Bone Marrow Transplant
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Medical Equipment
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Medication Management for a Behavioral Health condition
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Dialysis
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3. Do you have any hospitalizations, surgeries or procedures scheduled? Yes No
Date _________________ Type of Surgery/Procedure ________________________________
Name/Phone Number of Physician performing surgery/procedure _______________________________________________
Hospital/Facility________________________________________________
4. Have you been admitted to the hospital or seen in the emergency room in the past 6 months? Yes No
Reason _________________________________________________ Hospital _____________________________________
Date(s) of Service ________________________________________
5. Other Needs ___________________________________________________________
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I hereby authorize the above provider to give the Anthem
Blue Cross Transition Assistance Department any and all information and
medical records necessary to make an informed decision concerning my
request for Transition of Care/Continuity of Care. I understand that I
am entitled to a copy of this authorization form.
I also authorize Anthem Blue Cross to leave confidential information on my voice mail at the following number(s) listed above. Please check all that apply:
__ Home __ Cell __ Work __ Do NOT leave confidential information on my voice mail
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Signature of Patient if 18
or
over:
Date:
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Signature of Parent or Guardian if Patient is under 18: Date:
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