At Humana, our goal is to support you in maintaining an active and healthy lifestyle. We understand that making informed decisions about health care coverage can be a difficult task, which is why we're proud to offer the option of utilizing our Continuity Care form. This form provides individuals the assurance that they will receive consistent quality care from their primary care doctor or other healthcare professional throughout their life—from infancy through adulthood. With this form, members are able to obtain comprehensive continuity-of-care for preventative services, illnesses and chronic conditions. As your partner in health and wellness, we want to provide all the information you need within one simple document so that you can make informed decisions regarding your medical needs as easily as possible!
| Question | Answer |
|---|---|
| Form Name | Humana Continuity Care Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | continuity of care form, humana durable medical equipment forms, continuation of care form, humana of florida 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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(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.