Transition of Care

Anthem Blue Cross (Anthem) is happy to be your medical carrier and we look forward to helping you during your healthcare journey and 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 many need to have care transitioned.

If you do not have any ongoing care needs, you do not need to complete this form. 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 no. to reach you at


Hospital or provider's name

Hospital or provider's phone no.

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 permission to review the information provided and process your transition of care request.

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Anthem Blue Cross is the trade name of Blue Cross of California. Anthem BC Health Insurance Company is the trade name of Anthem Insurance Companies, Inc. Anthem Blue Cross, Anthem BC Health Insurance Company and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Use of the Anthem websites constitutes your agreement with our Terms of Use..