Great Bay Administrators Transition of Care Request Form

Transition of Care Request Form
Please use a separate form for each new enrollee. Please attach additional information if needed. **Please include letter from your prior carrier/coverage for any pre-authorized services**

If the transition of care request is related to prescription drugs, please contact the Prescription Management company on the back of your ID card.
Employer
Member ID
Employee Name

First NameLast Name
Home/Cell
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Patient's Name

First NameLast Name
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Employee
1. Is the patient currently receiving or recently completed treatment for cancer?
2. Is the patient scheduled for surgery or hospitalization after your effective date with EBPA?
3. Is the patient receiving dialysis treatment?
4. Is the patient a candidate for organ transplant?
5. Is there someone else authorized to speak with the coordinator about this patient?
If yes, please advise of Name/Relationship
6. If you did not answer “Yes” to any of the above questions, please describe the condition for which the patient requests Transition of Care.
7. Please complete the healthcare professional information request below.
Physician Information
- Health Care Professional Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Reason/Diagnosis
- Add Another Physician?
- Health Care Professional Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Reason/Diagnosis
- Add Another Physician?
- Health Care Professional Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Reason/Diagnosis
- 8. Is this patient expected to be in the hospital when coverage with EBPA begins or during the next 30 days?
- I hereby authorize the above health care professional to give Great Bay Administrators (GBA) or any affiliated company, all information and medical records necessary to make an informed decision concerning my request for Transition of Care benefits under GBA. I understand I am entitled to a copy of this authorization form.
- Signature
  
  First NameLast Name
- Today's Date
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- *PLEASE NOTE: GBA Transition of Care Program is not a substitute for professional medical advice. Use of the Transition of Care Program is completely voluntary and is provided at no cost to members. Services or medications that were covered on your prior plan may not be covered under your new plan. Please see your employer’s Summary Plan Description for complete benefit information.
- Attach additional documents here if needed: Please also include letter from your prior carrier/coverage for any pre-authorized services.
  
  (Limit of 5 Files)
  Cancelof
- Please note:
  
  The uploaded file must be DOC, DOCX, PDF, GIF, JPG, PNG, TIFF or TIF in format. The uploaded file must be less than 28MB in size.
  
  Renaming a non-supported file type to a supported file types will not be accepted. EXAMPLE: myreceipt.png to myreceipt.pdf
  
  Please ensure the file name is 25 characters or less.
Should be Empty: