Harbor Health

Transition of Care / Continuity of Care Form

Request authorization for transitional care benefits or continuity of care from providers that are not in network under your new health plan

TOC form instructions

Completing this form

Please complete this form if the patient is currently receiving ongoing medical care from providers that are not in-network under your new health plan, or has recently transferred from the Harbor Health Insurance Company (HHIC) network. In certain circumstances, benefits are available to pay for care from an out-of-network provider for a new member who is pregnant or in the middle of specific medical services. This allows the member to temporarily receive care from an out-of-network provider in the new network at the benefit or expense covered. For additional information, visit harborhealth.com and the Transition of Care Member Guide.

Important Note

Until Harbor Health has contacted a new provider, established a contract, and issued an approval for your TOC request, you will be responsible for the full cost of any non-emergency care you receive from the out-of-network provider.

Transition of Care coverage applies only if the provider agrees to comply with HHIC’s contractual terms, including prior authorization requirements, reimbursement at an agreed upon reimbursement rate, and adherence to quality and utilization standards.

Select Request Type*

Transition of Care (New to HHC) Continuity of Care (Provider or Facility Leaving Network)

Subscriber Information

Subscriber First Name*

Subscriber Last Name*

Subscriber Insurance ID*

Email Address*

Date of Birth*

Address*

City*

State*

ZIP Code*

Subscriber is same as patient

Patient Information

Complete if different from Subscriber

Patient First Name*

Patient Last Name*

Patient Insurance ID

Email Address*

Date of Birth*

Relation to Subscriber*

Address*

City*

State*

ZIP Code*

Provider Information

Please contact your provider to help you fill out this information.

Provider First Name*

Provider Last Name*

NPI ID*

Tax ID

Phone Number*

Fax Number*

Address*

City*

State*

ZIP Code*

Date of Last Visit

Date of Next Visit

Provider Specialty*

Medical Doctor & Specialty

PhD LCSW (Licensed Clinical Social Worker) LPC/LPCC (Licensed Professional Counselor/Licensed Clinical Professional Counselor)

Other

Medical or Behavioral Health*

Check All That Apply

Pregnancy Continuity of Care (Provider or Facility Leaving Network) Undergoing Postoperative Care Transplant List Physician Appointment Scheduled Undergoing a Course of Treatment for a Serious and Complex Condition Undergoing Institutional or Inpatient Care from the Provider Having Been Determined to be Terminally Ill

Authorization and Signature

I hereby authorize Harbor Health Insurance Company or designee to obtain any information and medical records from the providers and facilities listed in connection with making an informed decision regarding my request for a Transition of Care request or Continuity of Care request under my health plan. I understand that the data may be stored in and attached to a copy of medical information.

Please Note: Until Harbor Health has completed a review, established a contract with your provider and issued an approval for your TOC request, you will be responsible for the full cost of any non-emergency care you receive from the out-of-network provider.

Patient or Guardian Primary Phone*

Patient or Guardian Secondary Phone

Signature (Member or Guardian)*

Today's Date*