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
2 digit month, 2 digit day, 4 digit yearDate
Email
Parent Name (if applicable)
Parent Date of Birth (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Best Time to Be Reached
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature

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.

Rows	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)?
Do you receive any specialty injectable medications or infusions?

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.

Rows	Medication Name	Dose	Prescribing Provider
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7

Check the box if you need to add more medications.

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.
Should be Empty:

Rows	Medication Name	Dose	Prescribing Provider
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14

GHC-SCW: Transition of Care Form

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TRANSITION OF CARE