Computershare

Request for Authorization for Continuation of Care

Computershare

Continuation of Care Form

Computershare Members – to request authorization for continuity of care from your previous plan, please complete the form below. Include as much information as possible about the procedure or service you had authorized before moving to your Lucent Health plan. Lucent Health’s Concierge Care team will locate your member information and connect with you as soon as possible.

Subscriber/Member Information

Subscriber Full Name *

Member Full Name *

Member's Date of Birth *

Subscriber's ID # *

Relationship to Subscriber *

Mobile

Home

Work

Mobile

Home

Work

Condition/Diagnosis Information

Condition/Diagnosis for which Continuity of Care is being requested: *

Are you/the patient pregnant? If so, is the pregnancy high risk? *

No

Yes - not high risk

Yes - high risk

Is the request related to infusion or injection therapy? *

Yes

No

If yes, enter drug name

Is there an active acute condition being treated? *

Yes

No

If yes, enter condition

Is there a surgery or procedure scheduled? *

Yes

No

If yes, list procedure.

Are/were you or the patient hospitalized within 30 days of your enrollment? *

Yes

No

If yes, list date(s) of hospitalization

Is there active treatment from a recent (within 30 days) surgery? *

Yes

No

If yes, list surgery

Are you/the patient receiving dialysis? *

Yes

No

Are you/the patient a candidate for organ transplant? *

Yes

No

Is there an active course of chemotherapy or radiation? *

Yes

No

If all questions above are answered as “no”, please provide context for your request:

Is any hospitalization expected in the next 90 days? *

Yes

No

Please complete the following information related to the provider from whom you've been receiving care:

Upload any relevant documents here.

Click or drag a file to this area to upload.

Choose File

I hereby authorize the above health care provider to give Lucent Health, and any affiliates and contracted parties, any and all information and medical records necessary to make an informed decision concerning my request for Transition of Care/Continuity of Care. I understand I am entitled to a copy of this authorization request form. I also authorize Lucent Health Concierge Care to leave confidential information in my email or on my voice mail at the following number(s) listed above.

Please check all that apply: *

Home

Mobile

Email

Do NOT leave confidential information on my voicemail or email

Enter your full name below to e-sign this form. *

If the member is below the age of 18, please enter the parent or guardian's full name to e-sign.

Thank you for your message. It has been sent. If you need immediate attention, please call Lucent Health Concierge Care: (888) 201-4066

There was an error trying to submit your form. Please make sure all required fields are filled out. If you're still having trouble, try again later or call Lucent Health Concierge Care: (888) 201-4066

Computershare

Computershare

Subscriber/Member Information

Condition/Diagnosis Information

Questions? Members can also contact Lucent Health Concierge Care by calling (888) 201-4066 directly from Monday – Friday from 7 a.m. – 7 p.m. CST.

Questions? Members can also contact Lucent Health Concierge Care by calling (888) 201-4066 directly from Monday – Friday from 7 a.m. – 7 p.m. CST.