When navigating the complexities of healthcare, especially during transitions in insurance coverage or changes in healthcare providers, understanding how to maintain the continuity of your care is paramount. The Humana Request for Continuity of Care Form serves as a crucial tool for individuals facing such circumstances, ensuring they can continue receiving treatment from their current physicians under the same in-network level of benefits for a designated period. This assistance is invaluable for those requiring uninterrupted access to home healthcare services, durable medical equipment, or ongoing medical treatment for conditions ranging from pregnancy to chronic illnesses like diabetes, cancer, or heart disease. By completing and submitting this form within the required thirty-day window, patients can initiate a review process to determine their eligibility for continued care coverage. This process is not only designed to maintain the health and treatment outcomes of the patient but also to ease the administrative burdens often associated with healthcare transitions. Furthermore, the form includes comprehensive sections for member information and details regarding the treating physician, ensuring a streamlined communication channel with Humana. Submission instructions are clearly outlined, offering options to mail or fax the form, followed by a potential follow-up call from Humana, adding a personal touch to the process.
| Question | Answer |
|---|---|
| Form Name | Humana Continuity Care Form |
| Form Length | 1 pages |
| Fillable? | Yes |
| Fillable fields | 32 |
| Avg. time to fill out | 6 min 39 sec |
| Other names | humana continuation of care form, humana request of continuety form, humana durable medical equipment forms, humana request for continuity of care form |
Humana Request for Continuity of Care Form
Certain medical conditions may qualify you to continue receiving treatment from your physician and to be covered by Humana at the same
Examples of situations that might involve continuity of care include (please check any that may apply to you or a family member):
___ Home healthcare services you are currently receiving
___ Durable medical equipment that you are currently using
___ Ongoing active medical treatment, such as chemotherapy, dialysis, hospitalization, etc.
___ Pregnancy
___ Any of the following chronic medical conditions: |
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___ Diabetes |
___ Lupus |
___ Multiple Sclerosis |
___ Myasthenia Gravis |
___ Cystic Fibrosis |
___ Hemophilia |
___ Cancer |
___ Dermatomyositis |
___ Congestive Heart Failure |
___Asthma |
___ Coronary Artery Disease |
___ Amyotrophic Lateral Sclerosis (ALS) |
___ Kidney Disease |
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___ Chronic Inflammatory Demyelinating Polyradiculoneurophathy (CIPD)
___Other - Explain: _________________________________________________________________
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Member Information
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(First) |
(Middle I.) |
(Last) |
Member ID# |
Patient Name: |
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Subscriber Name: |
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Address: |
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City: |
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State: |
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Zip: |
Home Phone: ( |
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Work Phone: ( |
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Birthdate(MM/DD/YY): |
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Type of Plan (Check one): |
______HMO |
______PPO |
______POS |
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Name of Treating Physician: |
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Phone Number for Treating Physician: |
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Upon completion, please mail form to: |
Or fax this form to the following: |
SAN ANTONIO TEAM |
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HUMANA INC. |
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P.O. BOX 400029 |
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SAN ANTONIO, TEXAS 78229 |
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You may receive a phone call from Humana as a follow up to completing and submitting this form.