TRANSITION OF CARE

GHC-SCW: Transition of Care Form
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Welcome to Group Health Cooperative of South Central Wisconsin (GHC-SCW) Regardless of the clinic you choose, we can assist you with your health care needs during this transition period. To facilitate this, please complete the form below for each person in your family covered by this policy. If you have any questions, please contact the Care Management Department at (608) 257-5294.

Fill out and submit this online transition of care form to get started.

*For children 18 years and older, a release will be needed to discuss health information with parents.

TRANSITION OF CARE
New Member Name*
Date of Birth*

MonthDayYear
Date
Email*
Parent Name (if applicable)
Parent Date of Birth (if applicable)

MonthDayYear
Date
Phone Number*
Best Time to Be Reached
Date

MonthDayYear
Date
Signature

Clear

Please list any visits you had previously scheduled, which occur within 90 days of beginning coverage with GHC-SCW. Primary Care Provider and first time visits with a specialty provider are not eligible for transition of care coverage. Transition of Care services are not guaranteed and must be a covered benefit.

	Appointment	Date	Specialty	Diagnosis	Specialist Name and Clinic
Appt. #1
Appt. #2
Appt. #3
Appt. #4
Appt. #5
Appt. #6
Appt. #7

Do you use any durable medical equipment (ex. CPAP, infusion pumps, prosthetics)?

YesNo
Do you receive any specialty injectable medications or infusions?

YesNo

Please list the name, dose and prescribing provider of ALL prescriptions you currently use. Our pharmacy staff will review your list and contact you or work with your provider to address any potential coverage issues.

	Medication	Dose	Prescribing Provider

Please press "Submit" to complete your transition of care for submission.

If you have any questions, please contact the Care Management Department at (608) 257-5294.
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GHC-SCW: Transition of Care Form

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TRANSITION OF CARE