Transition of Care Auth Form (00272330).DOC

TRANSITION OF CARE SERVICES
If you, or a member of your family seeking coverage, are currently in a “plan of treatment” (which began prior
to your effective date) for a condition or treatment and your present physician is an out-of-network provider in
the BlueChoice® network, you can request special consideration to have your benefits paid at in-network levels
for a specific period of time. This will give you an opportunity to find a provider who participates in the
BlueChoice network.
Please complete this form so we can review how we can help you in your transition of care into the BlueChoice
HealthPlan network. Please also complete the authorization form and send them to this address or fax to 800610-5685:
BlueChoice HealthPlan of South Carolina
Post Office Box 6170 (AX-325)
Columbia, South Carolina 29260-9915
NAME AND ADDRESS:
DATE OF BIRTH:
________________________
______
TELEPHONE NUMBER:
PRIOR CARRIER:
PRIOR POLICY NUMBER:
HAVE YOU HAD A BREAK IN COVERAGE?

Yes

No
NAME OF PHYSICIAN
AND/OR HOSPITAL:
TELEPHONE NUMBER
OF PHYSICIAN AND/OR
HOSPITAL:
BlueChoice will review your individual situation and will advise you in writing of the decision about your
request.
(11355) Rev. 7/13
BlueChoice HealthPlan is an independent licensee of the Blue Cross and Blue Shield Association
AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION TO A THIRD PARTY
I authorize:
Specialist’s Name
Specialist’s Mailing Address
to disclose my protected health information, as defined below, to BlueChoice HealthPlan of South Carolina Inc. (“BlueChoice”):
(please check only one)

I authorize the above-named specialist to disclose any protected health information (except psychotherapy notes) that
BlueChoice may request. If applicable, this information may include information pertaining to chronic diseases, behavioral
health conditions, communicable diseases including HIV or AIDS and/or genetic information.
_____ Initial here to include any alcohol and substance abuse records, if applicable.
*This authorization will not apply to alcohol or substance abuse information unless specifically initialed.

I authorize the above-named specialist to disclose ONLY the following protected health information to BlueChoice:
The purpose for this disclosure is for determining the appropriate level of benefit reimbursement for Transition of Care (“TOC”)
services that are provided on or after the effective date of my BlueChoice coverage if I continue treatment with the above-named
specialist for certain diagnoses/medical conditions.
I understand that TOC services are subject to contractual limitations and exclusions as set forth in my subscriber contract. I understand
and agree that TOC services do not extend the contractual benefits in any way except to provide in-network level of benefits for a nonnetwork provider for a temporary time period. I also authorize BlueChoice to notify my provider of any TOC decisions with the nonparticipating specialist.
This authorization will expire on
occurs first.
/
/
or 12 months after termination of my coverage under BlueChoice, whichever
I understand that I may revoke this authorization at any time by sending written notice of my revocation to the address shown below.
I understand that revocation of this authorization will not affect any action taken by BlueChoice in reliance on this authorization
before my written notice of revocation was received.
I am making this authorization voluntarily and have had full opportunity to read and consider the contents of this authorization. I
understand that BlueChoice will not condition my enrollment in a health plan, eligibility for benefits or payment of claims upon my
signing this authorization. I further understand that information disclosed pursuant to this authorization may be subject to re-disclosure
by the recipient and may no longer be protected by federal or state privacy laws.
PATIENTS SIGNATURE:
PERSONAL REPRESENTATIVE’S SIGNATURE*:___
Date:
_________ Date:
*If the patient is younger than 16 years of age, or if this authorization is being completed by a personal representative on behalf of the
patient, the legal guardian or personal representative must attach legal documentation establishing authority to act as the individual’s
personal representative.
If you have any questions, or wish to get a copy of your signed authorization, please contact Customer Service:
BlueChoice HealthPlan of South Carolina Inc., P.O. Box 6170, Columbia, SC 29260 AX-435; 800-868-2528