DaVita Transition of Care Form

Anthem Blue Cross Blue Shield (Anthem) is happy to be your medical carrier and we look forward to helping you during your healthcare journey and addressing any needs you may have along the way. As part of your transition to Anthem, it's important for us to understand any special health needs or medical conditions that you or your family members may have. For example, if you are currently receiving care for a medical condition (such as pregnancy, chemotherapy, radiation therapy, or behavioral health therapy), have special medication needs or have an upcoming surgery scheduled, we can help with your questions or concerns. Please complete the following information if you are receiving ongoing care or are scheduled for care and one of our Nurse Managers will contact you. Please fill out the form completely and be sure to submit a separate form for each covered family member who may need to have care transitioned.

What are my options if my provider is not in-network and I am not in an active course of treatment? If a provider you've seen in the past 12 months is not in the Anthem network you can still submit a request to see your out-of-network provider at the in-network level until March 31, 2022. Complete the online link or download the form and mail or fax in to Anthem. Complete all required fields and include why you are seeing this provider in the field marked "Other".

Required field.
Part 1: Member Information:

Member last name

Member first name

Member middle initial

Date of birth

Gender	Male Female

Street Address

City

State

Zip Code


Part 2: Employee Information:
Employee (subscriber) last name

Employee (subscriber) first name

Employee (subscriber) middle initial

Best phone number to reach you at


Hospital or provider's name

Hospital or provider's phone number

Hospital or provider's street address

City

State

Zip Code


Do you have any hospitalizations, surgeries or procedures scheduled?	Yes No

If so, please provide the following:

Type of surgery/procedure:
Date Scheduled:

Please indicate the condition(s) and/or treatment(s) that require ongoing care:	Acute medical condition or trauma Chemotherapy/radiation therapy Chronic medical condition Durable medical equipment Mental health/substance abuse Organ or bone marrow transplant Outpatient therapy or procedure Planned surgery or hospitalization Pregnancy Prescription medications Other


Please provide us with as much detail about the item(s) marked above.


Thank you for completing the Transition of Care form. You will receive a call from a Nurse Manager to review your care needs as part of the transition to Anthem. Outreach and a decision regarding your transition of care request will be made within 15 calendar days. Please be aware that we (Anthem) are permitted to collect, use, and, share your Protected Health Information (PHI) for treatment, payment, and health care operations purposes. In these situations, member authorization for the collection, use, and sharing of PHI is not required under the HIPAA Privacy rule. We are requesting the information on this form with the intent to reach out to your providers and hospitals to use, collect, and share your PHI as is needed for treatment, payment, and health care operations purposes. For additional information about how your information may be collected, used, and shared, please refer to the Notice of Privacy Practices sent to you upon your enrollment. By submitting this Transition of Care form electronically via this web page, you agree that you are providing the legal equivalent of your signature, thereby giving Anthem Blue Cross Blue Shield permission to review the information provided and process your transition of care request.

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Anthem Blue Cross and Blue Shield

is the trade name for the following: In Connecticut: Anthem Health Plans, Inc. In Colorado, Rocky Mountain Hospital and Medical Service, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky. In Maine: Anthem Health Plans of Maine, Inc. In Missouri: RightCHOICE Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO Missouri, Inc. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi) and Compcare Health Services Insurance Corporation (Compcare). Independent licensees of the Blue Cross and Blue Shield Association. Serving residents and businesses in Indiana, Kentucky, Missouri, Ohio, Wisconsin, Colorado, Nevada, Connecticut, Maine, New Hampshire and Virginia (excluding the city of Fairfax, the town of Vienna and the area east of State Route 123). Use of the Anthem Web sites constitutes your agreement with our Terms of Use.