Transition of Care Form

Transition of Care Form

• Transition of Care Form – General
  Providers should forward a copy of the Transition of Care Form to any new members of Affinity Medical Group who is receiving prenatal care or is in active treatment for an acute or chronic condition with a non-participating provider. Visits through the current period of active treatment or up to 90 days, depending on the care needs and circumstances will be approved. If the member chooses to continue her prenatal care with an out of network provider, the visits may be approved if the member is receiving prenatal care during the second or third trimester of pregnancy and will continue through the provision of post-partum care directly related to the delivery.Patient’s receiving care of this kind from a non-participating provider, should complete this form. Any information provided will be kept confidential by Affinity Medical Group and will only be used in accordance with applicable privacy laws. Affinity may share this information with the patient’s primary care provider (PCP) and/or specialist and may contact the patient to facilitate continuity or continuation of care. Patient should complete and fax this form to the Clinical Operations Department at (855) 220-1423